46-year-old female, active smoker, over the past two days experienced chest pain accompanied by cold sweats. At addmission TA 80/60mmHg. Cardiac and pulmonary findings appear to be within normal parameters.
ECG at admission:
ECHO shows akinesis of all apical segments.
Coronarography was performed:
On call interventional cardiologist failed to recognize SCAD
PCI LAD:
Loss of flow distally after stent placement; on-call doctor ends the procedure.
ECG after cath lab
Despite ongoing maximal drug therapy, the patient continues to experience symptoms with persistent ST elevation on the ECG.
Coronarography after 12h:
An intimal flap is observed at the distal edge of the stent, potential proximal propagation and the distal occlusion.
IVUS:
Confirmed SCAD type IIb/IV
Further continuation of drug therapy: ASA 100 mg, Clopidogrel 75 mg, Pantoprazol 40 mg, Atorvastatin 40 mg, Bisoprolol 2,5 mg
Follow up 3 months
Coronarography:
The patient exhibits TIMI III flow with a residual intimal flap in the distal segment, yet remains asymptomatic without any new symptoms.
ECHO:
Based on what would you conclude that it is SCAD?
How would you perform the procedure if you have identified SCAD?