A Complex Case of Pregnancy-related Left Main Stem Spontaneous Coronary Artery Dissection.

Spontaneous coronary artery dissection (SCAD) is a less common cause of acute coronary syndrome. Pregnancy-related SCAD is uncommon, but often presents with a more severe phenotype. This report describes a 30-year-old woman with an anterior ST elevation MI, presenting 1 day postpartum. Left main stem (LMS) SCAD with extensive intramural haematoma (IMH) and resultant LMS occlusion was confirmed by angiography and intravascular imaging. Given the extent of disease, the patient underwent emergency cardiac surgery. Coronary flow was initially improved by decompressing the IMH using cutting balloons. The coronary wires were successfully left in situ during transfer in an effort to both maintain flow and allow the surgeon to identify true LMS. Ideally, SCAD can be managed conservatively given the risk of intervention worsening IMH, and hence myocardial ischaemia/MI. However, emergency revascularisation is indicated in cases of persistent ischaemia. This case demonstrates percutaneous therapies to bridge towards and help with subsequent surgical revascularisation.

Percutaneous coronary intervention in the elderly.

OBJECTIVE: To determine the clinical risks and procedural outcomes for elderly patients undergoing percutaneous coronary intervention (PCI). METHOD: A retrospective case-load analysis was performed of all patients over the age of 80 years, undergoing PCI, over a two-year period, in a tertiary referral hospital. Patient demographics, procedural details and in-hospital complications were obtained by reviewing patient notes. Twelve-month outcomes were obtained from telephone follow-up to the general practitioners and all surviving patients. RESULTS: There were 55 procedures. Procedural risk was high, with a median TIMI risk score of four (IQR 3-6) and a median additive EuroSCORE of nine (IQR 8-10). There was a 95% angiographic success rate. There were no in-hospital complications. Median Canadian Cardiovascular Society angina class fell from four (IQR 3-4) to one (IQR 0-1). At one year there were twelve deaths (10 cardiovascular), eight of these occurred in patients who had incomplete revascularisation. CONCLUSION: PCI can be performed in an elderly, high-risk population with a low in-hospital mortality and marked symptomatic benefit. However, there is a significant 1-year mortality, particularly in patients who are only suitable for partial revascularisation.

Traumatic left anterior descending artery-to-pulmonary artery fistula with delayed pericardial tamponade.

Traumatic coronary artery fistulas are rare, but 80% are secondary to penetrating injuries. Although the left coronary artery is involved in 46% of cases, these are usually associated with fistulas to the right ventricle. We describe a successful repair of a traumatic fistula from the proximal left anterior descending artery to the pulmonary artery after delayed presentation.