E-Case

JACC

Lots of interesting abstracts and cases were submitted for TCTAP 2024. Below are the accepted ones after a thorough review by our official reviewers. Don¡¯t miss the opportunity to expand your knowledge and interact with authors as well as virtual participants by sharing your opinion in the comment section!

TCTAP C-005

A Case Report: Young MI Patient With Spontaneous Coronary Artery Dissection in Both Lad and Rca Artery: What Should We Do?

By Quan Manh Nguyen, Tung Ngo

Presenter

Tung Ngo

Authors

Quan Manh Nguyen1, Tung Ngo1

Affiliation

Vietnam National Heart Institute, Vietnam1,
View Study Report
TCTAP C-005
Coronary - ACS/AMI

A Case Report: Young MI Patient With Spontaneous Coronary Artery Dissection in Both Lad and Rca Artery: What Should We Do?

Quan Manh Nguyen1, Tung Ngo1

Vietnam National Heart Institute, Vietnam1,

Clinical Information

Patient initials or Identifier Number

Relevant Clinical History and Physical Exam

Male patient, 35 years oldHistory: Hypertension, CKD for 1 year because of  IgA glomerular disease, currently being treated with Coversyl 5mg, Medrol 16 mg. No history of chest injuries, smoking, or drugs.Clinical presentation at admission: Chest angina, sweating in pain course, vomiting + NYHA III dyspnea 10 hours agoVital signs: Blood pressure 120/80 mmHg, Heart rate: 95 beats/minute,Signs of visit: Unremarkable

Relevant Test Results Prior to Catheterization

Bedside emergency echocardiography:Suspected hypokinesis of 1/3 of the interventricular septum toward the apex and apical regionThe left ventricular chamber is not dilated, and the left ventricular systolic function is within normal limitsCreatinin: 200 mcmol/lTroponin T hs: 777.9 -->4244 ng/lGOT/GPT: 183/87 U/LBlood gas test: PH 7.29.   PCO2: 42 mmHg    PO2: 96 mmHg     Lactat: 5 mmol/l



Relevant Catheterization Findings

Angiogram: SCAD type 1 at p-LAD caused TIMI 1 flow, Lcx seems normal. Likely SCAD at p-RCA, TIMI 3 flow. Maybe Thombus?

Interventional Management

Procedural Step

EBU 3.5. Right radial artery. wire: BMW  Runthrough. we perform slightly pre-dilate the deployed stent at LAD. Result: Good LAD TIMI Flow  STOP. We plan to perform 2nd coronary angiography after a few days. Right after PCI: Stable hemodynamic, symptoms relieved. After 48 hours: recurrent Chest pain, and dizziness. ECG: BAV III. Indications: Temporary pacemaker + Re- angiography. Result: LAD stent is still good. The RCA vessel wall is more 'solid' and the flow is still good ( better than 2 days ago) but the vessel wall is not as smooth then we performed IVUSIVUS image: RCA vessel wall hematoma + Ruptured atherosclerotic plaque --> PCI RCA with DES 4.0X 38 mm, TIMI 3 Flow. IVUS after stenting: No dissection, no malposition, good expansion. After 2nd PCI: Relieved chest pain. Heart rate is 90 beats/minute. Blood pressure 120/80 mmHg (Noradrenaline 0.1 ug/kg/pg).The patient is stable and discharged after 5 days


Case Summary

1. SCAD is rare but the incidence tends to be increased and dissection of multiple vessels occurs in 9-23%2. SCAD management: mostly conservation therapy. PCI can increase widespread dissection and be used for suitable patients: unstable hemodynamic/ arrhythmia, proximal dissection, or TIMI flow <=2¡¦ CABG is also another choice if LM or proximal dissection, after failed PCI, complications after attempted PCI, or refractory ischemia despite optimal medical therapy.3. PCI Technique aspects: Avoid pushing the catheter deeply, avoid vigorous injection of contrast medium, place extra 5-10mm stents at both ends, and direct stenting.