Spontan Koroner Arter Diseksiyonu
Özet
Spontan koroner arter diseksiyonu (SKAD), ateroskleroz, travma veya iyatrojenik bir neden olmaksızın epikardiyal koroner arterlerin diseksiyonudur. Koroner arter hastalığı risk faktörlerini taşımayan, özellikle genç ve orta yaş kadın hastalarda görülen bu hastalık, akut koroner sendrom serilerinin %1-4'ünü oluşturur ve sıklıkla yanlış tanılar alabilir. Bu çalışmada, bilinen kronik hastalığı ve kardiyak öyküsü bulunmayan, sadece oral kontraseptif kullanan 38 yaşında bir kadın hasta sunulmuştur. Göğüs ve sırt ağrısı şikayetiyle başvuran hastanın EKG'si yüksek lateral miyokart enfarktüsü ile uyumlu bulunmuş, ekokardiyografide ejeksiyon fraksiyonu %45 saptanmıştır. Koroner anjiyografide, sol ana koroner arter (LMCA) proksimalinden başlayıp tüm sol sistemi tutan SKAD tespit edilmiştir. Elektriksel instabilite ve hayati risk oluşturan bu yüksek riskli anatomi nedeniyle hastaya acil cerrahi kararı verilerek beating heart yöntemiyle üçlü bypass (CABG*3) yapılmıştır. Hasta, medikal tedavisinin ardından sorunsuz taburcu edilmiş ve üç aylık takibinde aktif yakınma gözlenmemiştir. Genellikle zamanla kendiliğinden iyileşen SKAD vakalarında rutin girişimsel tedavi önerilmezken (Klas 3), LMCA tutulumu gibi yüksek riskli durumlarda bypass cerrahisi en başarılı tedavi yöntemi olmaya devam etmektedir.
Spontaneous coronary artery dissection (SCAD) is the dissection of epicardial coronary arteries without atherosclerosis, trauma, or iatrogenic causes. Occurring predominantly in young and middle-aged female patients who do not exhibit risk factors for coronary artery disease, SCAD accounts for 1–4% of all acute coronary syndrome series and is frequently misdiagnosed. This case report presents a 38-year-old female patient with no known chronic disease or cardiac history, whose only regular medication was oral contraceptives. Presenting with chest and back pain, her ECG was compatible with high lateral myocardial infarction, and echocardiography revealed an ejection fraction of 45%. Coronary angiography demonstrated SCAD originating from the proximal left main coronary artery (LMCA) and involving the entire left system. Due to ongoing pain, electrical instability, and high-risk anatomy, urgent coronary artery bypass grafting (CABG*3) was performed on a beating heart. The patient was discharged without complications, and no active complaints were reported during the three-month follow-up. While routine interventional treatments are not recommended (Class 3) since SCAD lesions usually heal spontaneously over time, bypass surgery remains the most successful treatment modality in high-risk anatomical involvements such as LMCA disease.
Referanslar
Hayes SN, Kim ES, Saw J, Adlam D, Arslanian-Engoren C, Economy KE, et al. Spontaneous coronary artery dissection: current state of the science: a scientific statement from the American Heart Association. Circulation. 2018;137(19):e523-e57.
Pretty HC. Dissecting aneurysm of coronary artery in a woman aged 42: rupture. BmJ. 1931;1:667.
Vanzetto G, Berger-Coz E, Barone-Rochette G, Chavanon O, Bouvaist H, Hacini R, et al. Prevalence, therapeutic management and medium-term prognosis of spontaneous coronary artery dissection: results from a database of 11,605 patients. European Journal of Cardio-Thoracic Surgery. 2009;35(2):250-4.
Nishiguchi T, Tanaka A, Ozaki Y, Taruya A, Fukuda S, Taguchi H, et al. Prevalence of spontaneous coronary artery dissection in patients with acute coronary syndrome. European Heart Journal: Acute Cardiovascular Care. 2016;5(3):263-70.
DeMaio Jr SJ, Kinsella SH, Silverman ME. Clinical course and long-term prognosis of spontaneous coronary artery dissection. The American journal of cardiology. 1989;64(8):471-4.
Nakashima T, Noguchi T, Haruta S, Yamamoto Y, Oshima S, Nakao K, et al. Prognostic impact of spontaneous coronary artery dissection in young female patients with acute myocardial infarction: A report from the Angina Pectoris-Myocardial Infarction Multicenter Investigators in Japan. International journal of cardiology. 2016;207:341-8.
Elkayam U, Jalnapurkar S, Barakkat MN, Khatri N, Kealey AJ, Mehra A, et al. Pregnancy-associated acute myocardial infarction: a review of contemporary experience in 150 cases between 2006 and 2011. Circulation. 2014;129(16):1695-702.
Rogowski S, Maeder MT, Weilenmann D, Haager PK, Ammann P, Rohner F, et al. Spontaneous Coronary Artery Dissection: Angiographic Follow-Up and Long-Term Clinical Outcome in a Predominantly Medically Treated Population. Catheterization and cardiovascular interventions : official journal of the Society for Cardiac Angiography & Interventions. 2017;89(1):59-68.
Kwon T-G, Gulati R, Matsuzawa Y, Aoki T, Guddeti RR, Herrmann J, et al. Proliferation of coronary adventitial vasa vasorum in patients with spontaneous coronary artery dissection. JACC: Cardiovascular Imaging. 2016;9(7):891-2.
Luong C, Starovoytov A, Heydari M, Sedlak T, Aymong E, Saw J. Clinical presentation of patients with spontaneous coronary artery dissection. Catheterization and Cardiovascular Interventions. 2017;89(7):1149-54.
Lettieri C, Zavalloni D, Rossini R, Morici N, Ettori F, Leonzi O, et al. Management and long-term prognosis of spontaneous coronary artery dissection. The American journal of cardiology. 2015;116(1):66-73.
Rashid HN, Wong DT, Wijesekera H, Gutman SJ, Shanmugam VB, Gulati R, et al. Incidence and characterisation of spontaneous coronary artery dissection as a cause of acute coronary syndrome—a single-centre Australian experience. International journal of cardiology. 2016;202:336-8.
Saw J, Aymong E, Sedlak T, Buller CE, Starovoytov A, Ricci D, et al. Spontaneous coronary artery dissection: association with predisposing arteriopathies and precipitating stressors and cardiovascular outcomes. Circulation: Cardiovascular Interventions. 2014;7(5):645-55.
Collet J-P, Thiele H, Barbato E, Barthélémy O, Bauersachs J, Bhatt DL, et al. 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: the Task Force for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation of the European Society of Cardiology (ESC). European heart journal. 2021;42(14):1289-367.
Members WC, Lawton JS, Tamis-Holland JE, Bangalore S, Bates ER, Beckie TM, et al. 2021 ACC/AHA/SCAI guideline for coronary artery revascularization: executive summary: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Journal of the American College of Cardiology. 2022;79(2):197-215.
Tweet MS, Eleid MF, Best PJ, Lennon RJ, Lerman A, Rihal CS, et al. Spontaneous coronary artery dissection: revascularization versus conservative therapy. Circulation: Cardiovascular Interventions. 2014;7(6):777-86.
Lempereur M, Fung A, Saw J. Stent mal-apposition with resorption of intramural hematoma with spontaneous coronary artery dissection. Cardiovascular Diagnosis and Therapy. 2015;5(4):323.
