Spontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndrome (ACS) that mostly occurs in middle-aged women. In recent years, it has been attracting attention as a major cause of ACS in younger women. Several case series, middle-scale sample size retrospective cohort studies, and a recent large prospective study have all identified many features of this disorder along with gaps in the literature. Almost all patients with SCAD present ACS and account for 1–4% of all ACS cases. In case of hemodynamically stable patients with thrombolysis in myocardial infarction flow grade 2 to 3, conservative treatment is recommended because healing of the dissected vessel is commonly expected. However, revascularization strategies for patients with SCAD are poorly established. Intracoronary imaging modalities such as intravascular ultrasound and optical coherence tomography have a potential for preventing technical failure during angioplasty and improving the success rate of revascularization, but it has not yet fully elucidated. From existing retrospective studies, long-term mortality is low even though the recurrence of SCAD is not rare. This review will summarize the clinical characteristics, management, and prognosis of SCAD.
Objective: We assessed the safety of Suvorexant, an orexin receptor antagonist, on cardiac and respiratory function in patients who underwent off-pump coronary artery bypass grafting (OPCAB) retrospectively. Materials and methods: We investigated 66 patients including 16 women (mean age 71.6 ± 8.1 years) who underwent OPCAB alone at our hospital. Patients were categorized as those received orexin receptor antagonist after OPCAB (S-group, n=35) or without orexin receptor antagonist (N-group, n=31), and the following data were analyzed between both groups. Results: The incidence of postoperative delirium was significantly lesser in the S-group than in the N-group (N vs. S =32.3% vs. 8.6%, p=0.004). Intensive care unit stay was also significantly shorter in the S-group compared with the N-group (N vs. S=4.6 ± 1.1 vs. 4.1 ± 0.8 days, p=0.040). No significant intergroup difference was observed in arterial blood gas measurement (mean the potential of hydrogen, partial pressure of oxygen, the partial pressure of carbon dioxide, base excess, and respiratory rate) and circulation statement (systolic arterial blood pressure, pulmonary artery wedge pressure, heart rate, cardiac index, and mixed venous oxygen saturation) before and after the administration of Suvorexant. Conclusion: Orexin receptor antagonists didn’t worsen the cardiac function and the respiratory function in patients who underwent OPCAB.
Kommerell's diverticulum is a very rare congenital aortic arch anomaly with an estimated incidence of 0.04-0.1%. Few studies have reported on acute ST-segment elevation myocardial infarction in patients with Kommerell's diverticulum on the right-sided aortic arch. The anatomical anomaly makes coronary artery catheterization difficult. If such a case is suspected during the patient examination before coronary artery revascularization, the appropriate arterial approach site should be carefully considered for revascularization as early as possible.
Selecting an appropriate therapeutic strategy for severe aortic stenosis (AS) is challenging in presence of ST-elevation myocardial infarction (STEMI). We report a case in which antegrade balloon aortic valvuloplasty (A-BAV) played an important role in temporizing a patient with severe AS and reduced left ventricular ejection fraction (LVEF) due to STEMI. Our patient was an 85-year-old man who experienced anterior STEMI (peak creatine kinase = 5286 U/L) and fulfilled the criteria of classical LFLG-AS (aortic valve area = 0.68 cm², LVEF = 16%, and MPG = 20 mmHg). He had heart failure symptoms refractory to optimized therapy, including intra-aortic balloon pump (IABP) counterpulsation, even after successful recanalization of the coronary artery. Intervention for severe AS was required; however, the patient was identified to be at high risk for surgery (Society of Thoracic Surgeons score = 16.56%), and our hospital is not a transcatheter aortic valve replacement-capable facility. We performed A-BAV for hemodynamic restoration. A few days after successful A-BAV, tapering of norepinephrine and weaning of IABP were initiated. A cardiac rehabilitation program was initiated during the intensive care period, and which facilitated the patient to be discharged. A-BAV achieved convalescence with no recurrence of heart failure hospitalization at 510 days of follow-up.
Although acute type A aortic dissection with obstruction of the coronary artery is frequently fatal, some case reports have shown the effectiveness of stenting as a bridge to definitive surgery. We report a case of a 72-year-old woman referred to our hospital with acute onset chest pain. Her history included stent grafting for an abdominal aortic aneurysm three months before surgery, and percutaneous coronary intervention for the left circumflex artery and right coronary artery one year prior to admission. Electrocardiogram findings indicated ST-segment elevation. Emergency coronary angiography showed a 99% stenosis at the proximal part of the left anterior descending artery. Intravascular ultrasound study revealed a hematoma located from the proximal part of the left anterior descending artery to the left main trunk. After implanting a drug eluting stent from the left main trunk to the left anterior descending artery, computed tomography revealed an acute type A aortic dissection. Ascending aortic replacement and coronary artery bypass grafting were performed. Successful implantation of the stent at the left coronary artery was a bridge to surgery for the patient.