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A 35-year-old woman was evaluated for presyncope several days after giving birth. The results of physical examination were unremarkable, but her electrocardiogram showed transient ST depressions in leads II, III, aVF, and V4 through V6. An echocardiographic stress test performed with the use of dobutamine showed wall-motion abnormalities on provocation. A coronary angiogram showed normal coronary arteries, with haziness at the right coronary arterial ostium (Panel A, arrow). Subsequent evaluation by intravascular ultrasound imaging showed a nonocclusive ostial dissection (Panel B, arrow; and Video Clip 1) with a free-moving flap. A conservative therapeutic approach was chosen, and the patient was treated with aspirin, amlodipine, and enoxaparin for three weeks. She was asymptomatic until four months after angiography, when she began to experience increasing discomfort in her chest. At 11 months, exercise myocardial-perfusion imaging with the use of thallium-201 showed inferolateral ischemia. Repeated angiography showed the same haziness at the proximal right coronary artery (Video Clip 2), and repeated intravascular ultrasound imaging showed worsening of the intimal dissection at this site (Video Clip 3). A stent was deployed, with a good result (Video Clip 4). Eight months after the stent was placed, the patient was well and had no symptoms. Repeated exercise myocardial-perfusion imaging with the use of thallium-201 showed normal perfusion.
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