Predictors of adverse cardiac events of coronary myocardial bridging diagnosed with computed tomography angiography.

AIMS: Myocardial bridging (MB) is a frequent congenital anomaly of the epicardial coronary arteries commonly considered a benign condition. However, in some cases a complex interplay between anatomical, clinical and physiology factors may lead to adverse events, including sudden cardiac death. Coronary CT angiography (CCTA) emerged as the gold standard noninvasive imaging technique for the evaluation of MB. Aim of the study was to evaluate MB prevalence and anatomical features in a large population of patients who underwent CCTA for suspected CAD and to identify potential anatomical and clinical predictors of adverse cardiac events at long-term follow-up. METHODS AND RESULTS: Two-hundred and six patients (mean age 60.3 ± 11.8 years, 128 male) with MB diagnosed at CCTA were considered. A long MB was defined as ≥25 mm of overlying myocardium, whereas a deep MB as ≥2 mm of overlying myocardium. The study endpoint was the sum of the following adverse events: cardiac death, bridge-related acute coronary syndrome, hospitalization for angina or bridge-related ventricular arrhythmias and MB surgical treatment. Of the 206 patients enrolled in the study, 9 were lost to follow-up, whereas 197 (95.6%) had complete follow-up (mean 7.01 ± 3.0 years) and formed the analytic population. Nineteen bridge-related events occurred in 18 patients (acute coronary syndrome in 7, MB surgical treatment in 2 and hospitalization for bridge-related events in 10). Typical angina at the time of diagnosis and long MB resulted as significant independent predictors of adverse outcome. CONCLUSIONS: Typical angina and MB length ≥ 25 mm were independent predictors of cardiac events.

Coronary physiology thresholds associated with microvascular obstruction in myocardial infarction.

OBJECTIVES: To ascertain whether invasive assessment of coronary physiology soon after recanalisation of the culprit artery by primary percutaneous coronary intervention is associated with the development of microvascular obstruction by cardiac magnetic resonance in patients with ST-segment elevation myocardial infarction (STEMI). METHODS: Between November 2020 and December 2021, 102 consecutive patients were prospectively enrolled in five tertiary centres in Italy. Coronary flow reserve (CFR) and index of microvascular resistance (IMR) were measured in the culprit vessel soon after successful primary percutaneous coronary intervention. Optimal cut-off points of IMR and CFR to predict the presence of microvascular obstruction were estimated, stratifying the population accordingly in four groups. A comparison with previously proposed stratification models was carried out. RESULTS: IMR>31 units and CFR≤1.25 yielded the best accuracy. Patients with IMR>31 and CFR≤1.25 exhibited higher microvascular obstruction prevalence (83% vs 38%, p<0.001) and lower left ventricular ejection fraction (45±9% vs 52±9%, p=0.043) compared with those with IMR≤31 and CFR>1.25, and lower left ventricular ejection fraction compared with patients with CFR≤1.25 and IMR≤31 (45±9% vs 54±7%, p=0.025). Infarct size and area at risk were larger in the former, compared with other groups. CONCLUSIONS: IMR and CFR are associated with the presence of microvascular obstruction in STEMI. Patients with an IMR>31 units and a CFR≤1.25 have higher prevalence of microvascular obstruction, lower left ventricular ejection fraction, larger infarct size and area at risk. TRIAL REGISTRATION NUMBER: NCT04677257.

#FullPhysiology: a systematic step-by-step guide to implement intracoronary physiology in daily practice.

#FullPhysiology is a comprehensive and systematic approach to evaluate patients with suspected coronary disease using PressureWire technology (Abbott Vascular, Santa Clara, CA, USA). This advancement in technology enables the investigation of each component of the coronary circulation, including epicardial, microvascular, and vasomotor function, without significantly increasing procedural time or technical complexity. By identifying the predominant physiopathology responsible for myocardial ischemia, #FullPhysiology enhances precision medicine by providing accurate diagnosis and facilitating tailored interventional or medical treatments. This overview aims to provide insights into modern coronary physiology and describe a systematic approach to assess epicardial flow-limiting disease, longitudinal physiological vessel analysis, microvascular and vasomotor dysfunction, as well as post- percutaneous coronary intervention (PCI) physiological results.

Preoperative angiography-derived fractional flow reserve may predict coronary artery bypass grafting occlusion and disease progression.

BACKGROUND: Graft occlusion after coronary artery bypass grafting (CABG) has been associated with competitive flow of native coronary arteries. OBJECTIVES: To assess with coronary computed tomography angiography (CCTA) graft occlusion and coronary artery disease (CAD) progression of native vessels after CABG and their relationship with angiography-derived vessel fractional flow reserve (vFFR) performed before surgery. METHODS: Between 2006 and 2018, serial vFFR analyses were obtained before CABG in each major native coronary vessel from two institutions. All patients underwent follow-up CCTA. RESULTS: In 171 consecutive patients, serial preoperative angiograms were suitable for vFFR analysis of 298 grafted and 59 nongrafted vessels. Median time between CABG and CCTA was 2.1 years. Preoperative vFFR was assessed in 131 left anterior descending artery (LAD), 132 left circumflex artery (LCX) and 94 right coronary aretry (RCA) and was less than 0.80 in 255 of 298 bypassed vessels. Graft occlusion was observed at CCTA in 28 of 298 grafts. The median preoperative vFFR value of native coronaries was higher in occluded compared with patent grafts (0.75 vs. 0.60, P < 0.001) and was associated with graft. The best vFFR cut-off to predict graft occlusion was 0.67. Progression of CAD was higher in grafted than in nongrafted vessels (89.6 vs. 47.5%, P < 0.001). Pre-CABG vFFR predicted disease progression of grafted native vessels (AUC = 0.83). CONCLUSION: Preoperative vFFR derived from invasive coronary angiography was able to predict graft occlusion and CAD progression of grafted coronary arteries.

Noblestitch® system for PFO closure: A novel but judicious alternative to traditional devices-A case report.

Background: Percutaneous suture-mediated patent foramen ovale (PFO) closure has recently been used with the aim of avoiding double-disc nitinol device implantation. This novel technique has been carried out successfully in several centers offering PFO closure with an effective closure rate comparable to conventional double-disc devices. Case summary: A 50-year-old man, a pentathlon athlete, suffering from a previous left-sided ischemic stroke, underwent percutaneous closure of a permanent right-to-left shunt via PFO with a large fenestrated septum primum aneurysm at another institution. The NobleStitch® system was successfully implanted using local anesthesia and under angiographic-fluoroscopic monitoring. He was discharged home on aspirin 100 mg daily with a moderate residual shunt on contrast transthoracic echocardiography (cTTE) that persisted unaltered at subsequent controls. After 7 months, unable to resume sporting activity because of physical discomfort and dyspnea on exertion, the patient asked for a second opinion at our Heart and Brain clinic. Two-dimensional (2D) TTE showed septum primum laceration next to a radiopaque polypropylene knot with a moderate bidirectional shunt located at the fenestrated septum primum far from the PFO site. A catheter-based closure of the septal defect was therefore planned under local anesthesia and rotational intracardiac echo monitoring. An equally sized discs 28.5 mm × 28.5 mm Flex II UNI occluder (Occlutech GmbH, Jena, Germany) was successfully implanted across the atrial septal defect without complications. The patient was discharged in good clinical conditions; dual antiplatelet therapy (aspirin 100 mg/daily and clopidogrel 75 mg/daily) was recommended for 2 months and then single antiplatelet therapy (aspirin100 mg/daily) up to 6 months. Abolition of the residual shunt was confirmed at 1- and 6-month follow-up by contrast transcranial Doppler and 2D color Doppler cTTE. Discussion: Closing a PFO with a suture-base system, without leaving a device implant behind, may be a cutting-edge technology and potential alternative to traditional devices. Nevertheless, meticulous selection of the PFO anatomies by 2D TEE is key to a successful closure procedure in order to avoid complications that must be managed again with a second percutaneous procedure or by surgery.

The SALINE Technique for the Treatment of the No-Reflow Phenomenon during Percutaneous Coronary Intervention in STEMI.

BACKGROUND: Primary percutaneous coronary intervention (pPCI) performed for STEMI may be complicated by the "no-reflow" phenomenon. AIMS: A super-selective intracoronary injection of saline solution through a thrombus aspiration catheter (SALINE technique), was investigated for the treatment of no-reflow as compared with the standard care of therapy (SCT). METHODS: Among the 1471 patients with STEMI undergoing pPCI between May 2015 and June 2020, 168 patients developed no-reflow. Primary endpoints were the incidence of ST-segment resolution (STR) ≥ 70% at 90 min after PCI and the rate of flow restoration (TIMI flow grade 3 with an MBG > 1). The secondary endpoint was the incidence of major adverse cardiac and cerebrovascular events at 3 years follow-up. RESULTS: After propensity score matching analysis, patients treated with SALINE showed STR ≥ 70% in twelve out of the sixteen patients (75.0%), compared to only three patients out of the sixteen in the SCT control group (19.0%), (p < 0.004). SALINE was associated with a higher probability of final TIMI flow grade 3 with an MBG > 1, as shown in fourteen out of sixteen patients (87.5%), as compared to only seven out of sixteen patients in the SCT group (43.8%), (p < 0.03). MACCE at 3 years follow-up occurred in only one patient (6.3%) in the SALINE group, as compared to eight patients (50%) in the SCT group (p = 0.047). CONCLUSIONS: The SALINE technique showed to be a safe and effective strategy to reduce "no-reflow" in STEMI patients as assessed by significant STR, improvement of TIMI flow grade, and better 3-year outcomes.

Diagnostic performance of exercise stress tests for detection of epicardial and microvascular coronary artery disease: the UZ Clear study.

BACKGROUND: Cardiac stress tests remain the cornerstone for evaluating patients suspected of having obstructive coronary artery disease (CAD). Coronary microvascular dysfunction (CMD) can lead to abnormal non-invasive tests. AIMS: We sought to assess the diagnostic performance of exercise stress tests with indexes of epicardial and microvascular resistance as reference. METHODS: This was a prospective, single-arm, multicentre study of patients with an intermediate pretest probability of CAD and positive exercise stress tests who were referred for invasive angiography. Patients underwent an invasive diagnostic procedure (IDP) with measurement of fractional flow reserve (FFR) and index of microvascular resistance (IMR) in at least one coronary vessel. Obstructive CAD was defined as diameter stenosis (DS) >50% by quantitative coronary angiography (QCA). The objective was to determine the false discovery rate (FDR) of cardiac exercise stress tests with both FFR and IMR as references. RESULTS: One hundred and seven patients (137 vessels) were studied. The mean age was 62.1±8.7, and 27.1% were female. The mean diameter stenosis was 37.2±27.5%, FFR was 0.84±0.10, coronary flow reserve was 2.74±2.07, and IMR 20.3±11.9. Obstructive CAD was present in 39.3%, whereas CMD was detected in 20.6%. The FDR was 60.7% and 62.6% with QCA and FFR as references (p-value=0.803). The combination of FFR and IMR as clinical reference reduced the FDR by 25% compared to QCA (45.8% vs 60.7%; p-value=0.006). CONCLUSIONS: In patients with evidence of ischaemia, an invasive functional assessment accounting for the epicardial and microvascular compartments led to an improvement in the diagnostic performance of exercise tests, driven by a significant FDR reduction.

Position-based dynamics simulator of vessel deformations for path planning in robotic endovascular catheterization.

A major challenge during autonomous navigation in endovascular interventions is the complexity of operating in a deformable but constrained workspace with an instrument. Simulation of deformations for it can provide a cost-effective training platform for path planning. Aim of this study is to develop a realistic, auto-adaptive, and visually plausible simulator to predict vessels' global deformation induced by the robotic catheter's contact and cyclic heartbeat motion. Based on a Position-based Dynamics (PBD) approach for vessel modeling, Particle Swarm Optimization (PSO) algorithm is employed for an auto-adaptive calibration of PBD deformation parameters and of the vessels movement due to a heartbeat. In-vitro experiments were conducted and compared with in-silico results. The end-user evaluation results were reported through quantitative performance metrics and a 5-Point Likert Scale questionnaire. Compared with literature, this simulator has an error of 0.23±0.13% for deformation and 0.30±0.85mm for the aortic root displacement. In-vitro experiments show an error of 1.35±1.38mm for deformation prediction. The end-user evaluation results show that novices are more accustomed to using joystick controllers, and cardiologists are more satisfied with the visual authenticity. The real-time and accurate performance of the simulator make this framework suitable for creating a dynamic environment for autonomous navigation of robotic catheters.

Conduction disorders after transcatheter aortic valve implantation: A comparison between SAPIEN 3 and SAPIEN 3 Ultra balloon-expandable valves.

Background: Conduction disorders (CD) are the most common complications after Transcatheter Aortic Valve Implantation (TAVI). The last generation of Edwards balloon expandable valves, the SAPIEN 3 Ultra (S3U), is provided with an external sealing skirt that aims to further reduce paravalvular leakage (PVL) compared to SAPIEN 3 (S3) and could potentially lead to higher CD rate. We sought to investigate the rate of new-onset CD in patients undergoing TAVI with the S3 or S3U valve. Methods: We included 582 consecutive patients undergoing TAVI in a single high-volume Center. Patients with previously implanted pacemaker and Valve in valve procedures were excluded. CD rate was evaluated early after implantation and at discharge. Results: No significant difference in the overall CD rate was found between S3 and S3U patients both immediately after the procedure (S3 45.5% vs. S3U 41.8%, p = 0.575) and at discharge (S3 30.4% vs. S3U 35.6%, p = 0.348) with low rate of permanent pacemaker implantation (S3 6.3% vs. S3U 5.5%, p = 0.749). No significant differences were found also in patients with pre-existing atrial fibrillation (S3 8.2% vs. S3U 5%, p = 0.648). A significantly lower rate of PVL was found with S3U compared to S3 (S3 42% vs. S3U 26%, p = 0.007). According to the manufacturer's guidelines we confirmed that S3U were implanted in a significantly higher position compared to S3 (S3 4.89 ± 1.57 mm vs. S3U 4.47 ± 1.36 mm, p = 0.001). Conclusion: No significant difference in the rate of CD, including the need for PPM implantation, was found in patients undergoing TAVI with the S3 compared to S3U. Moreover, S3U significantly reduced the PVL rate.

Transcatheter mitral valve replacement: there is still work to be done.

Transcatheter mitral valve replacement (TMVR) is a novel therapeutic option for patients with severe mitral regurgitation (MR) at high or prohibitive surgical risk. Most TMVR technologies under investigation use either a trans-apical or a trans-septal approach via dedicated multistep anchoring systems. Transcatheter mitral valve replacement offers several potential advantages over transcatheter repair, notably a greater and more sustained MR reduction. At the same time, significant engineering challenges and potential disadvantages must be acknowledged. Preclinical and clinical studies have shown promising results, demonstrating TMVR feasibility. Nevertheless, further development, testing, and trials are needed before considering TMVR as a definitive therapeutic option for MR in a wide range of anatomical scenarios.

Intravascular Lithotripsy in Calcified Coronary Lesions: A Single-Center Experience in "Real-World" Patients.

Objectives: This study aims to describe the outcome of intravascular lithotripsy (IVL) when used with different indications and to assess the short- and long-term outcomes of IVL-facilitated percutaneous coronary intervention (PCI). Background: Intravascular lithotripsy can improve the results of PCI of calcified coronary lesions with a low rate of periprocedural complications. Methods: A total of 105 consecutive patients with 110 calcified lesions underwent IVL. A total of 87 de novo lesions were treated by IVL with the following indications: 25 before attempting other balloon-based devices (primary IVL), 51 after the failure of non-compliant balloon dilatation (secondary IVL), and 11 after stent implantation because of stent under expansion (bailout IVL). In 23 lesions, IVL was used for the treatment of in-stent restenosis (ISR). Effectiveness (angiographic success) and safety [major adverse cardiovascular events (MACEs) and IVL-related procedural complications] endpoints were assessed. Results: Angiographic success was achieved in 84.6% of lesions. Early MACEs were periprocedural MI only, ranging from 6.7 to 20% depending on MI definition. The flow-limiting dissections rate was 2.7%. A total of five (4.5%) IVL balloons ruptured during treatment with subsequent vessel perforation in 1 case. MACEs at 12 months were 13.3%, with TLR occurring in 8 lesions (12% primary IVL, 0% secondary IVL, 0% bailout IVL, and 21.7% IVL for ISR, p = 0.002). Conclusion: Treatment of calcified coronary lesions with IVL in a "real-world" setting can be performed with high success, low rate of procedural complications, and an acceptable MACEs rate. Target lesion failure may be more frequent when IVL is performed for the treatment of ISR due to calcium-mediated stent under expansion.

Prevalence of Coronary Microvascular Disease and Coronary Vasospasm in Patients With Nonobstructive Coronary Artery Disease: Systematic Review and Meta-Analysis.

Background A relevant proportion of patients with suspected coronary artery disease undergo invasive coronary angiography showing normal or nonobstructive coronary arteries. However, the prevalence of coronary microvascular disease (CMD) and coronary spasm in patients with nonobstructive coronary artery disease remains to be determined. The objective of this study was to determine the prevalence of coronary CMD and coronary vasospastic angina in patients with no obstructive coronary artery disease. Methods and Results A systematic review and meta-analysis of studies assessing the prevalence of CMD and vasospastic angina in patients with no obstructive coronary artery disease was performed. Random-effects models were used to determine the prevalence of these 2 disease entities. Fifty-six studies comprising 14 427 patients were included. The pooled prevalence of CMD was 0.41 (95% CI, 0.36-0.47), epicardial vasospasm 0.40 (95% CI, 0.34-0.46) and microvascular spasm 24% (95% CI, 0.21-0.28). The prevalence of combined CMD and vasospastic angina was 0.23 (95% CI, 0.17-0.31). Female patients had a higher risk of presenting with CMD compared with male patients (risk ratio, 1.45 [95% CI, 1.11-1.90]). CMD prevalence was similar when assessed using noninvasive or invasive diagnostic methods. Conclusions In patients with no obstructive coronary artery disease, approximately half of the cases were reported to have CMD and/or coronary spasm. CMD was more prevalent among female patients. Greater awareness among physicians of ischemia with no obstructive coronary arteries is urgently needed for accurate diagnosis and patient-tailored management.

Case Report: Key Role of the Impella Device to Achieve Complete Revascularization in a Patient With Complex Multivessel Disease and Severely Depressed Left Ventricular Function.

Background: Left ventricle (LV) assist devices may be required to stabilize hemodynamic status during complex, high-risk, and indicated procedures (CHIP). We present a case in which elective hemodynamic support with the Impella CP device was essential to achieve complete revascularization with PCI in a patient with complex multivessel disease and severely depressed LV function. Case Summary: A 45-year-old male with no previous history of cardiovascular disease presented to the emergency department for new onset exertional dyspnoea. Echocardiography showed severely depressed LV function (EF 27%) that was confirmed with cardiac magnetic resonance. Two chronic total occlusions (CTOs) of the proximal right coronary artery (RCA) and left circumflex coronary artery (LCx) were found at coronary angiography. After Heart Team evaluation, PCI with Impella hemodynamic support was planned. After crossing and predilating the CTO of the LCx, ventricular fibrillation (VF) occurred. No direct current (DC) shock was performed because the patient was conscious thanks to the support provided by the Impella pump. About 1 min later, spontaneous termination of VF occurred. Afterwards, the two CTOs were successfully treated with good result and no complications. Recovery of LV function was observed at discharge. At 9 months, the patient had no symptoms and echocardiography showed an EF of 60%. Discussion: In this complex high-risk patient, hemodynamic support was essential to allow successful PCI. It is remarkable that the patient remained conscious and hemodynamically stable during VF that spontaneously terminated after 1 min, likely because the Impella pump provided preserved coronary perfusion and LV unloading. This case confirms the pivotal role of Impella in supporting CHIP, particularly in patients with multivessel disease and depressed LV function.

Corrigendum: Catheter-based Closure of a Post-infective Aortic Paravalvular Pseudoaneurysm Fistula With Severe Regurgitation After Two Valve Replacement Surgeries: A Case Report.

[This corrects the article DOI: 10.3389/fcvm.2021.693732.].

Catheter-based Closure of a Post-infective Aortic Paravalvular Pseudoaneurysm Fistula With Severe Regurgitation After Two Valve Replacement Surgeries: A Case Report.

Backgsround: Infective endocarditis (IE) of prosthetic valves is a dire complication of cardiac valve replacement surgery and is associated with high rates of morbidity and mortality. Case Summary: A 72-year-old woman with multiple comorbidities underwent surgical replacement of the aortic valve with a mechanical prosthetic valve after recurrent IE. After 10 years, IE recurred and the mechanical valve was surgically replaced with a bioprosthetic valve. Ten years later, severe heart failure developed due to severe paravalvular leak (PVL) caused by an aortic annulus abscess complicated by a paravalvular pseudoaneurysm fistula (PPF). The patient was deemed at prohibitive surgical risk and a catheter-based PVL closure procedure was planned. However, the interventional procedure was delayed several months due to the Covid-19 pandemic with progressive heart failure worsening. Despite an acute satisfactory result of the PPF transcatheter closure and a significant clinical improvement, the patient died 10 months later due to multiorgan failure. It is likely that this was due, at least in part, to the long treatment delay caused by the unprecedented strain on the healthcare system. Discussion: In patients at high surgical risk, early diagnosis and prompt interventional treatment of severe PVL are crucial for improving expectancy and quality of life. However, the recent outbreak of COVID-19 caused deferral of elective and semi-elective structural heart disease procedures (SHD) as in our case. Thus, a proactive and vigilant stance on managing SHD should be a priority even in the context of the COVID-19 pandemic.

Revival of a forgotten valve: use of the percutaneous clip for the treatment of tricuspid regurgitation.

Tricuspid regurgitation (TR) is common in patients with left-sided valvular heart disease and is independently associated with increased mortality and morbidity because it leads to right-sided heart failure and recurrent hospitalization. The prognostic benefit of isolated TR surgical repair or replacement is unclear and medical treatment of decompensated right heart failure alone does not prevent the progression of the disease. Recently, minimal invasive catheter-based techniques have emerged as a feasible and effective option for TR treatment in selected high-risk patients who would clinically benefit from tricuspid valve repair. We provide an overview of the current state of transcatheter TR treatment using the edge-to-edge technique.

Implementing Coronary Computed Tomography Angiography in the Catheterization Laboratory.

Coronary computed tomography angiography (CCTA) is now an established tool in the diagnostic work-up of patients suspected to have coronary artery disease. Yet, its usefulness beyond this phase has not been fully explored. The current review focuses on the implementation of CCTA as a tool to plan and guide coronary interventions in the catheterization laboratory. Specifically, we explore the potential of CCTA to improve patient selection for percutaneous revascularization, provide the rationale for better resource use, and present a novel approach to incorporate 3-dimensional CT guidance for percutaneous coronary interventions.

Vessel Fractional Flow Reserve and Graft Vasculopathy in Heart Transplant Recipients.

BACKGROUND: Cardiac allograft vasculopathy (CAV) remains the Achilles' heel of long-term survival after heart transplantation (HTx). The severity and extent of CAV is graded with conventional coronary angiography (COR) which has several limitations. Recently, vessel fractional flow reserve (vFFR) derived from COR has emerged as a diagnostic computational tool to quantify the functional severity of coronary artery disease. PURPOSE: The present study assessed the usefulness of vFFR to detect CAV in HTx recipients. METHODS: In HTx patients referred for annual check-up, undergoing surveillance COR, the extent of CAV was graded according to the criteria proposed by the international society of heart and lung transplantation (ISHLT). In addition, three-dimensional coronary geometries were constructed from COR to calculate pressure losses using vFFR. RESULTS: In 65 HTx patients with a mean age of 53.7 ± 10.1 years, 8.5 years (IQR 1.90, 15.2) years after HTx, a total number of 173 vessels (59 LAD, 61 LCX, and 53 RCA) were analyzed. The mean vFFR was 0.84 ± 0.15 and median was 0.88 (IQR 0.79, 0.94). A vFFR ≤ 0.80 was present in 24 patients (48 vessels). HTx patients with a history of ischemic cardiomyopathy (ICMP) had numerically lower vFFR as compared to those with non-ICMP (0.70 ± 0.22 vs. 0.79 ± 0.13, p = 0.06). The use of vFFR reclassified 31.9% of patients compared to the anatomical ISHLT criteria. Despite a CAV score of 0, a pathological vFFR ≤ 0.80 was detected in 8 patients (34.8%). CONCLUSION: The impairment in epicardial conductance assessed by vFFR in a subgroup of patients without CAV according to standard ISHLT criteria suggests the presence of a diffuse vasculopathy undetectable by conventional angiography. Therefore, we speculate that vFFR may be useful in risk stratification after HTx.

[Peripartum spontaneous coronary artery dissection: a case report]. / Dissezione coronarica spontanea peripartum: un caso clinico.

Spontaneous coronary artery dissection (SCAD) accounts approximately for 0.2% of cases of acute coronary syndrome. It is defined "spontaneous" in absence of any coronary wall damage. This disease affects primarily young women in good health, with no risk factors for coronary artery disease, especially during the postpartum period. Since the clinical presentation varies widely from no symptoms to typical angina and sudden cardiac death, SCAD incidence is underestimated.A 40-year-old woman, in the 8th week after delivery, was admitted to our emergency department because of acute chest pain, and a diagnosis of inferior and posterior non-ST-elevation myocardial infarction was made. Emergency coronary angiography showed a small SCAD of the distal segment of a little marginal branch. Because of the small dimension of the dissection, optimal medical therapy was started. However, two days later, symptoms recurred and the ECG showed an anterior ST-elevation myocardial infarction. The patient was therefore transferred to the cath lab and coronary angiography showed extensive dissection of the left anterior descending coronary artery with good angiographic result. Percutaneous coronary intervention was performed and three drug-eluting stents were implanted.No retrospective studies or randomized clinical trials are available to guide the best treatment option in patients with SCAD, because of the wide variety of clinical presentation and the rarity of the pathology. Early and correct diagnosis of SCAD is key for adequate management. First, the site and precise quantification of lesion severity should be assessed with multiple angiographic projections. Intravascular ultrasound and optical coherence tomography can provide additional information about the entry point of the lesion. Hemodynamic status and extension of the myocardium at risk should be also evaluated to determine the best therapeutic strategy. Since the presence of SCAD may be associated with aneurysm formation and dissections of other arteries, screening of the arterial tree may be useful, especially of the supra-aortic trunks and splanchnic circulation.