To the Editor: Spontaneous coronary dissection is a rare butserious complication in the peripartum and postpartum periods.1,2However, we disagree with Frimerman and Meisel (Nov. 11 issue)3about the diagnosis in the Images in Clinical Medicine article.3First, the luminal structure that is described as dissectionextends to the outside of the vessel. Second, the injectionof contrast medium does not show a possible connection betweenthe lumen and the luminal space in question. Third, the luminalspace remains visible after stent deployment. Given the normallythin appearance of coronary arteries in young persons4 and thecharacteristic anatomical course of cardiac veins, we believethat what is seen is a cardiac vein, not arterial dissection.We think this is the correct interpretation of these particularintravascular images. At least, these video clips do not showsigns of dissection. Although this patient's diagnosis remainsa mystery, refractory coronary spasm, which can also reportedlybe 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{at}crci.stanford.edu
Dr. Fitzgerald reports having served as a consultant for BostonScientific.
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. [CrossRef][Web of Science][Medline]
Lee FH, Yeung AC, Fowler MB, Fitzgerald PJ. Spontaneous postpartum coronary dissection. Circulation 1999;99:721-721. [Free Full Text]
Frimerman A, Meisel SR. Peripartum dissection of the right coronary artery. N Engl J Med 2004;351:e18-e18. [Free Full Text]
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. [Free Full Text]
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. [CrossRef][Web of Science][Medline]
The authors reply: This young patient had chest pain with ischemia,confirmed by ST-segment depression, echocardiographic stresstesting, and myocardial-perfusion imaging. The angiogram showedhaziness at the very proximal right coronary artery, and respectiveintravascular 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 contrastmaterial did not enter the false lumen because of a small communicationand free flow within the defect. Moreover, after deploymentof the stent, the haziness disappeared, the false lumen seenon intravascular ultrasound images almost disappeared, and thepatient was asymptomatic for more than a year. We do not thinkthat the false lumen is a coronary vein because it is not ofthe proper size and shape. We are not aware of the presenceof a large vein so close to the ostium of the right coronaryartery. On the basis of these considerations, this case is nota "mystery" but, rather, a rare case of peripartum spontaneouscoronary 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
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