(158) Pregnancy-Associated SCAD Managed by Orthotopic Heart Transplant

Introduction: The incidence of peripartum myocardial infarction is estimated at 6 in 100,000 deliveries, with over one in four due to spontaneous coronary artery dissection (SCAD). The management of pregnancy-associated SCAD (P-SCAD) is challenging with a wide array of approaches described. Here we present a case of P-SCAD managed by attempted PCI, emergent CABG, and ultimately heart transplant.

Description: The patient was a 39 year old G3P1 with a past medical history of smoking, hypertension, and stroke. She had an induction of labor at 38 weeks due to pre-eclampsia and was discharged home after delivery.

Four days later she was readmitted for preeclampsia with severe features and developed chest pain radiating to the left arm and back. Serum troponins peaked at 11,500 although there was no EKG or echocardiographic evidence of ischemia. She was initially managed conservatively, but repeat episodic chest pain prompted a cardiac catheterization where she was found to have extensive SCAD involving the left main, circumflex, and LAD. Attempts to wire the true lumen resulted in propagation of the dissection, and she was sent to the operating room for emergent CABG with placement of an axillary Impella.

She was unable to wean from support and later interrogation revealed poor flow through both bypass grafts. She was listed and underwent heart transplant four days later. Unfortunately, on day one following transplant, she had a brief 3 minute cardiac arrest of unknown etiology with resulting hypoxic ischemic injury. She eventually underwent placement of a tracheostomy and PEG-tube and was transferred to the cardiology service for further management and long-term care planning.

Discussion: This case is representative of the diverse management options for patients with P-SCAD. Traditional ACS algorithms favor early intervention, however they may not be appropriate in these cases. Many SCAD lesions managed conservatively recanalize on their own. PCI is frequently challenging and can worsen the dissection, and CABG is difficult due to poor targets with poor postoperative graft flow a common outcome. Heart transplant is an option for patients failing other therapies. Unfortunately our case was complicated by a cardiac arrest with subsequent neurological dysfunction despite otherwise good graft function.