September 8th, 2014
Anteroseptal MI and Left-Main Dissection in a Pregnant Woman
Harsh Golwala, MD and James Fang, MD
A 25-year-old woman who is gravida 4, para 2 and is 32 weeks pregnant presents to the emergency department with sudden-onset chest pain that started while she was preparing her kids for school in the morning. An electrocardiogram reveals anteroseptal MI with ST-segment elevations in leads V1–V4 and reciprocal depressions in leads II, III, and aVF.
The patient is immediately taken to the cath lab, where she has a finding of spontaneous distal left-main dissection extending into the left anterior descending artery with TIMI 3 flow.
After transfer to the hospital’s tertiary care center, the patient becomes free of chest pain on a 10-μg/minute nitroglycerin drip, from which she is then weaned in a few hours. ECG shows a >50% reduction in ST-segment changes. The patient is monitored in the CCU. Echocardiography reveals a normal LV ejection fraction with no wall-motion abnormalities.
Questions:
1. What management approach would you choose for this pregnant woman?
2. Which antiplatelet/anticoagulation strategies should be used?
3. What is the most appropriate revascularization strategy? When should it be initiated?
4. How should delivery of the child be conducted?
Response:
September 22, 2014
1. Coronary dissections are generally best managed conservatively. They generally heal with anticoagulation strategies. PCI is often complicated by trying to identify and wire the true lumen; complications are common (see the ACCF/AHA PCI guidelines).
2. I would consider using heparin and a short-acting glycoprotein IIb/IIIa antagonist in order to facilitate delivery.
3. As noted, coronary dissections are best managed conservatively, given the difficulties in identifying the true lumen with either by PCI or surgery.
4. I would consider a cesarean delivery to control the hemodynamic situation of the mother. Direct surgical management of the wound allows for careful use of anticoagulants and antiplatelet agents.
It is also important to screen this woman for fibromuscular dysplasia. Other conditions in the differential diagnosis include Ehlers–Danlos syndrome, giant-cell arteritis, Takayasu’s arteritis, and other true connective-tissue disorders.
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What management approach would you choose for this pregnant woman?
Taking in consideration the patient is stable, asymtomatic, has a TIMI 3 flow and the Echocardiography reveals a normal LV ejection fraction with no wall-motion abnormalities, and the excellent response to nitro.
You could recommend initiate treatment with heparin, nitro and beta-blockers in this patients, since approximately 50% of these patients show spontaneous healing of the dissection, while an even greater percentage are asymptomatic.
But taking in consideration she has a distal left-main dissection, with the extension into the left anterior descending artery the area in risk is mayor so you could recommend stenting.
Remember in-hospital mortality is low regardless of initial treatment, percutaneous coronary intervention is associated with high rates of complication. Risks of SCAD recurrence and major adverse cardiac events in the long term emphasize the need for close follow up.
In this case is very important the experience an ability of the operator and of course his opinion, remember Primum non nocere.
2. Which antiplatelet/anticoagulation strategies should be used?
Heparin unfractionated. Aspirin in standby.
3. What is the most appropriate revascularization strategy? When should it be initiated?
Wait for the spontaneous healing if not, stent.
4. How should delivery of the child be conducted?
Start induction of pulmonary maturity.
Some people wait 2 or 3 weeks after a MI to achieve resolution of the infarcted area, but there are no studies showing that such a delay improves the result.
The selection of vaginal or Caesarean section it is not better to the other in such patients and the decision should be made on a case-by-case basis.
Heparin should be withdrawn 4 h before caesarean section or at the onset of labour and resumed 6 – 12 h after either surgical or vaginal delivery.
the best part in this case is that she got stabilised on a minimal NTG infusion and the worst part is she needs immediate intervention in view of left main dissection extending into LAD.
i feel i m an ammature kid for handling this case, but my sugestions are,
1. Angioplasty with stent placement.
2. Heparin LMWH will be better
3. Stent Placement.
4. the baby should be delivered by C sec under GA.