Spontaneous left main coronary artery dissection complicated by pseudoaneurysm formation in pregnancy: role of CT coronary angiography

Spontaneous coronary artery dissection (SCAD) is a rare cause of acute myocardial ischemia [1]. It is defined as hemorrhagic separation of the coronary artery media with creation of a false lumen in the absence of precipitating factors. SCAD is often fatal. However, the prognosis is favorable for patients who survive the initial event [1-3]. Revascularization procedures and conservative medical management strategies have been applied in patients presenting with SCAD. Surgical intervention is indicated in cases of SCAD when there is propagation of the dissection plane or luminal narrowing resulting in myocardial ischemia with significant hemodynamic compromise [4].Many published reports linked pregnancy with an increased risk for SCAD [2]. The underlying mechanisms are unclear but likely multifactorial in nature. In a recent review article, the mortality rate for pregnant patients presenting with SCAD was reported to be 38% [5]. There is no consensus opinion regarding whether to treat these patients medically or by revascularization. In this regard, the decision to perform diagnostic tests and revascularization procedures must also consider both maternal and fetal circumstances.We present a clinical case of a pregnant patient presenting with SCAD of left main coronary artery (LMC) complicated by the formation of a pseudoaneurysm, which led to significant myocardial damage and onset of congestive heart failure. CT coronary angiography was used to document the persistence of dissection and pseudoaneurysm, thereby helping to guide the decision to proceed with surgical revascularization.A previously healthy 26-year-old female in the 34th week of gestation was awakened from sleep by the sudden onset of severe substernal chest pain. On admission, blood pressure was 95/63 mmHg and, heart rate 87/min. An S4 detected on cardiopulmonary exam. EKG performed showed normal sinus rhythm with marked ST-elevations in leads V1–V4. She was taken to coronary angiography, which revealed