Pregnancy-Associated Spontaneous Coronary Artery Dissection: Anesthetic Considerations

Spontaneous coronary artery dissection (SCAD) accounts for one-third of all peripartum myocardial infarction. Peripartum SCAD is associated with increased severity. We surmise that altered maternal cardiac physiology increases susceptibility to SCAD and warrants consideration when managing cardiac ischemia. One week after vaginal delivery, a 35-year-old woman with no known medical history developed multivessel SCAD and cardiogenic shock after attempted percutaneous coronary intervention, requiring rescue CABG and percutaneous VAD placement. She ultimately received an orthotopic heart transplant. SCAD disproportionally affects women, hormonal effects may contribute, however SCAD may herald occult arteriopathies. Pregnancy alters hemodynamics; cardiac output and circulating volume increase up to 150% at delivery. Most SCAD is successfully managed medically; procedural intervention is rare. Pharmacologic attenuation of the high-output state and procedural intervention may require consideration of fetal wellbeing. Pregnancy presents innate challenges for managing cardiac ischemia, especially in the presence of an undelivered fetus.