An Unusual Case of Spontaneous Left Main Coronary Dissection in A Young Pregnant Woman Treated with Percutaneous Intervention

Spontaneous coronary artery dissection (SCAD) is the spontaneous separation of
the coronary artery wall, not iatrogenic or related to trauma. SCAD is an uncommon
disease in which the left main coronary involvement is rare. SCAD is commonly nonatherosclerotic,
according to predisposing factors (fibromuscular dysplasia, female
gender, pregnancy, ecc) and precipating factors (intense exercise/emotional stress,
vigorous Valsalva type activities, abuse of recreational drugs, ecc). Diagnosis of SCAD
is first based on clinical grounds and then confirmed with imaging. Access to different
imaging techniques, in particular coronary angiography (CA) and intravascular
ultrasound (IVUS), is crucial to recognize and manage SCAD in acute care settings.
We report an unusual case of high risk acute coronary syndrome due to the left main
coronary dissection in a 33 year-old pregnant woman at 19th week of gestation. According
to coronary angiography and clinical unstable conditions, LM was successfully treated
with a provisional stenting technique. Intra-procedural IVUS was helpful to obtain good
stent apposition and confirm the underlying intramural hematoma. Before invasive
strategy, the cooperation of the heart team was crucial because we not only considered
some protocols to reduce radiation and contrast agent exposure, but also planned a
follow up in order to organize the delivery and minimize potential stress conditions and
bleeding risk to the fetus.
SCAD should not be underestimated when associated to ACS and pregnancy: urgent
coronary angiography and bail-out adjunctive imaging are crucial. Improvements in
materials and techniques together with a protocol for radiation/contrast media exposure
and for antithrombotics drugs administration could make percutaneous interventions
feasible and safe in these scenarios.