Spontaneous coronary artery dissection 'storm' in post-partum: a case report.

Background: Spontaneous coronary artery dissection (SCAD) remains a rare form of acute coronary syndrome (ACS) in young women. It is not always easy to diagnose and its management can be complex, particularly in the case of severe forms.

Case summary: A 29-year-old Mahorese woman presented with non-ST-elevation acute coronary syndrome 72 h after vaginal delivery of an uncomplicated twin pregnancy. Coronary angiography revealed a SCAD of the left anterior descending artery (LAD) treated medically. At Day 4, urgent coronary angiography was performed due to recurrent ACS with unfavourable evolution on LAD SCAD with worsening flow and appearance of right coronary artery (RCA) dissection. Percutaneous coronary intervention (PCI) was performed with drug-eluting stent (DES) implantation in LAD under optical coherence tomography (OCT) guidance. At Day 6, the patient suffered from inferior ST segment elevation myocardial infarction due to extension of the RCA SCAD with occlusion of the posterior descending artery. Once again, under OCT guidance, PCI was performed in RCA with implantation of four DES. At Day 8, the patient presented with an intra-hospital cardiac arrest by electromechanical dissociation. Urgent coronary angiography revealed a diffuse extension of the SCAD to the circumflex artery and the left main trunk (LM). Rescue PCI of the LM was performed under OCT guidance, and a femoro-femoral extracorporeal life support was implanted because of haemodynamic instability. With no hope of left ventricular ejection fraction recovery, the patient eventually benefited from a heart transplant 12 days after the first ACS with excellent evolution.

Discussion: Although the majority of SCAD have a favourable outcome with spontaneous healing, it is important to keep in mind that certain severe forms exist and could require specific management as PCI under OCT guidance and potential transfer to surgical centres where heart transplants and mechanical circulatory support are available.