Peripartum Dissection of the Right Coronary Artery
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《新英格兰医药杂志》
To the Editor: Spontaneous coronary dissection is a rare but serious complication in the peripartum and postpartum periods.1,2 However, we disagree with Frimerman and Meisel (Nov. 11 issue)3 about the diagnosis in the Images in Clinical Medicine article.3 First, the luminal structure that is described as dissection extends to the outside of the vessel. Second, the injection of contrast medium does not show a possible connection between the lumen and the luminal space in question. Third, the luminal space remains visible after stent deployment. Given the normally thin appearance of coronary arteries in young persons4 and the characteristic anatomical course of cardiac veins, we believe that what is seen is a cardiac vein, not arterial dissection. We think this is the correct interpretation of these particular intravascular images. At least, these video clips do not show signs of dissection. Although this patient's diagnosis remains a mystery, refractory coronary spasm, which can also reportedly be addressed with intracoronary stent placement,5 might be considered.
Hideaki Kaneda, M.D.
Junya Ako, M.D.
Peter J. Fitzgerald, M.D., Ph.D.
Stanford University
Stanford, CA 94305
ivus@crci.stanford.edu
Dr. Fitzgerald reports having served as a consultant for Boston Scientific.
References
Koul AK, Hollander G, Moskovits N, Frankel R, Herrera L, Shani J. Coronary artery dissection during pregnancy and the postpartum period: two case reports and review of literature. Catheter Cardiovasc Interv 2001;52:88-94.
Lee FH, Yeung AC, Fowler MB, Fitzgerald PJ. Spontaneous postpartum coronary dissection. Circulation 1999;99:721-721.
Frimerman A, Meisel SR. Peripartum dissection of the right coronary artery. N Engl J Med 2004;351:e18-e18.
Fitzgerald PJ, St Goar FG, Connolly AJ, et al. Intravascular ultrasound imaging of coronary arteries: is three layers the norm? Circulation 1992;86:154-158.
Gaspardone A, Tomai F, Versaci F, et al. Coronary artery stent placement in patients with variant angina refractory to medical treatment. Am J Cardiol 1999;84:96-8, A8.
The authors reply: This young patient had chest pain with ischemia, confirmed by ST-segment depression, echocardiographic stress testing, and myocardial-perfusion imaging. The angiogram showed haziness at the very proximal right coronary artery, and respective intravascular ultrasound images showed a wide, crescent-shaped, false lumen encircling more than half of the arterial circumference, with a free-moving dissection flap entering the true lumen. Neither type of imaging showed spasm. The injected contrast material did not enter the false lumen because of a small communication and free flow within the defect. Moreover, after deployment of the stent, the haziness disappeared, the false lumen seen on intravascular ultrasound images almost disappeared, and the patient was asymptomatic for more than a year. We do not think that the false lumen is a coronary vein because it is not of the proper size and shape. We are not aware of the presence of a large vein so close to the ostium of the right coronary artery. On the basis of these considerations, this case is not a "mystery" but, rather, a rare case of peripartum spontaneous coronary dissection, which was successfully sealed by a stent, with excellent long-term results.
Aaron Frimerman, M.D.
Simcha R. Meisel, M.D.
Hillel Yaffe Medical Center
38100 Hadera, Israel
Hideaki Kaneda, M.D.
Junya Ako, M.D.
Peter J. Fitzgerald, M.D., Ph.D.
Stanford University
Stanford, CA 94305
ivus@crci.stanford.edu
Dr. Fitzgerald reports having served as a consultant for Boston Scientific.
References
Koul AK, Hollander G, Moskovits N, Frankel R, Herrera L, Shani J. Coronary artery dissection during pregnancy and the postpartum period: two case reports and review of literature. Catheter Cardiovasc Interv 2001;52:88-94.
Lee FH, Yeung AC, Fowler MB, Fitzgerald PJ. Spontaneous postpartum coronary dissection. Circulation 1999;99:721-721.
Frimerman A, Meisel SR. Peripartum dissection of the right coronary artery. N Engl J Med 2004;351:e18-e18.
Fitzgerald PJ, St Goar FG, Connolly AJ, et al. Intravascular ultrasound imaging of coronary arteries: is three layers the norm? Circulation 1992;86:154-158.
Gaspardone A, Tomai F, Versaci F, et al. Coronary artery stent placement in patients with variant angina refractory to medical treatment. Am J Cardiol 1999;84:96-8, A8.
The authors reply: This young patient had chest pain with ischemia, confirmed by ST-segment depression, echocardiographic stress testing, and myocardial-perfusion imaging. The angiogram showed haziness at the very proximal right coronary artery, and respective intravascular ultrasound images showed a wide, crescent-shaped, false lumen encircling more than half of the arterial circumference, with a free-moving dissection flap entering the true lumen. Neither type of imaging showed spasm. The injected contrast material did not enter the false lumen because of a small communication and free flow within the defect. Moreover, after deployment of the stent, the haziness disappeared, the false lumen seen on intravascular ultrasound images almost disappeared, and the patient was asymptomatic for more than a year. We do not think that the false lumen is a coronary vein because it is not of the proper size and shape. We are not aware of the presence of a large vein so close to the ostium of the right coronary artery. On the basis of these considerations, this case is not a "mystery" but, rather, a rare case of peripartum spontaneous coronary dissection, which was successfully sealed by a stent, with excellent long-term results.
Aaron Frimerman, M.D.
Simcha R. Meisel, M.D.
Hillel Yaffe Medical Center
38100 Hadera, Israel