September 8th, 2014
Anteroseptal MI and Left-Main Dissection in a Pregnant Woman
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.
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?
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.