Journal of Invasive Cardiology

Case Report. A 46-year-old female presented to a community hospital with acute coronary syndrome. One week prior to presentation, the patient had experienced chest tightness lasting 1 hour, occurring 1 day after lifting furniture. On the day of presentation, she developed recurrent chest tightness at rest. In the emergency room, her physical examination was normal. Her blood pressure was 109/60 mmHg. Serial electrocardiograms revealed transient minimal anterior ST-elevation and lateral T-wave inversions. Initial cardiac biomarkers were normal. The patient received aspirin, clopidogrel, metoprolol, nitrates and enoxaparin, and her chest pain resolved after 1.5 hours. However, her cardiac enzymes steadily rose over the next 2 days to a creatine kinase level of 567 U/L (normal < 200 U/L), CK-MB of 58 ng/ml (normal < 4 ng/ml), and troponin I of 28.1 ng/ml (normal < 0.3 ng/ml).
The patient had a history of depression and mitral valve prolapse, no risk factors for atherosclerosis and no family history of coronary disease or sudden cardiac death. There was no history of recreational drug use, recent trauma or recent pregnancy. Her only medication was duloxetine hydrochloride 60 mg daily. Upon transfer to our hospital, coronary angiography demonstrated left anterior descending artery (LAD) dissection from the takeoff of the first septal branch to the distal LAD (Figure 1). The remainder of the coronary arterial tree was angiographically normal. Intravenous heparin and tirofiban were administered. Via a 6 Fr JL4 Launcher guide catheter (Medtronic, Inc., Minneapolis, Minnesota), a 0.014 inch x 190 cm Balance guidewire (Guidant Corp., Indianapolis, Indiana) was manipulated into the second diagonal artery. Intravascular ultrasound (IVUS) examination using a 40 MHz Atlantis SR Pro catheter (Boston Scientific Corp., Natick, Massachusetts) revealed a LAD medial dissection with the true lumen compressed by a hematoma-filled false lumen (Figure 1). Minimal lumen area in the lesion segment was 1.79 mm². No communication was visualized between the true and false lumens, and the normal vessel wall was observed from the proximal dissection edge to the left main trunk. IVUS also confirmed the location of guidewire in the true lumen of the LAD. The mid-LAD was directly stented with a 3.0 x 32 mm Taxus Express2 stent (Boston Scientific). Repeat angiography revealed no obvious proximal LAD dissection (Figure 2), but IVUS examination demonstrated dissection extending proximal to the stent, prompting deployment of a 3.5 x 12 mm Taxus Express2 stent proximal to and overlapping with the initial stent. Subsequent IVUS examination confirmed stent coverage of the proximal dissection edge. The minimal stent area was 5.82 mm². By coronary angiography, LAD flow was observed to be TIMI 3, though there remained a dissection plane visible in the distal vessel (Figure 3). Postprocedure, the patient had no further chest pain and her cardiac enzymes trended downward. She was discharged the following day on aspirin and clopidogrel.