63 CHEST PAIN AND THE DYNAMIC EVOLUTION OF SPONTANEOUS CORONARY ARTERY HEMATOMA. (15th December 2022)

• Record Type: Journal Article
• Authors: Franzino, Marco; Costa, Francesco; De Ferrari, Tommaso; Vizzari, Giampiero; Di Bella, Gianluca; Micari, Antonio; Carerj, Scipione
• Is Part Of: European heart journal supplements. Volume 24(2022)Supplement K
• Publication Date: 2022-12-15
• Subjects: Cardiology -- Periodicals; Cardiology -- Europe -- Periodicals; 616.12005
• DOI: 10.1093/eurheartjsupp/suac121.329
• Languages: English
• ISSNs: 1520-765X

Abstract

Abstract: Background: Spontaneous coronary intramural hematoma (SCIH) is a rare but underdiagnosed condition, with dynamic evolution. Clinical presentation: A 45-year-old woman was admitted to the emergency department with chest pain and fever in the previous days. Markers of myocardial injury were elevated, white blood cell count and C-reactive protein were mildly elevated, whereas D-dimer, chest X-ray and ECG were normal. Transthoracic echocardiography showed inferior wall hypokinesia, so an urgent coronary angiogram was performed showing no evidence of obstructive coronary artery disease. Investigations: Cardiac magnetic resonance (CMR) was performed two days later showing inferior wall ischemic pattern (Figure 1) and ECG showed changes in the inferior leads with T waves inversion. A second coronary angiogram with planned intravascular imaging was than performed and showed a critical stenosis of the mid-distal right coronary artery determining functional vessel occlusion (Figure 2). Coronary vasospasm was ruled-out after intracoronary nitrates infusion and intravascular ultrasound (IVUS) showed diffuse intramural hematoma of the ostial, proximal and mid-segment of the right coronary artery with subocclusive stenosis at the mid segment with no evidence of atherosclerosis (Figure 3). Management: Considering the clinical and radiological evidence of evolving myocardial injury, conservative management was excluded, and direct stenting of the lesion was performed with IVUS guided implantation of four overlapping drug-eluting stents. Conclusion: Our case highlights the dynamic and treacherous nature of spontaneous coronary intramural hematoma, causing initial symptoms of myocardial ischemia without evident coronary obstruction, and then rapidly evolving in a severe and life-threatening coronary occlusion upon hematoma expansion. Higher level diagnostic testing such as CMR and intravascular imaging were instrumental for correct diagnosis and treatment in this complex scenario. Figure 1 Figure 2 Figure 3