Abstract 4343962: A Shocking Postpartum Course

Description of Case: A 34-year-old female G3P3 presented at 6 weeks postpartum with acute chest pain, dizziness, and bradycardia. Troponin in ED was 79, then 873 at 2-hours and 3,613 at 6-hours. Echocardiogram revealed an ejection fraction (EF) of 55% with mild diastolic dysfunction and apical hypokinesis. LHC revealed spontaneous coronary artery dissection (SCAD) of the mid-distal LAD (type III) with TIMI-3 flow, treated conservatively. She started aspirin 81 mg daily and discharged after 3 days of observation. 12 hours later, she had recurrence of crushing chest pain and presented again to the ED (troponin elevated to 9,599; EKG found anterior STEMI). Repeat LHC found severe multivessel SCAD with dissection flap extending throughout left main artery, occlusive SCAD distal to D2 in the LAD, and occlusion of the left circumflex artery at the ostium. Impella CP was placed due to cardiogenic shock. Injection of contrast in the right femoral artery suggested newly diagnosed fibromuscular dysplasia (FMD). She underwent emergent 3-vessel CABG and Impella 5.5 placement. Postoperative EF was estimated at 15%-20% and she started on milrinone. Impella was removed on postoperative day (POD) #10, and milrinone weaned off on POD #13. She discharged home on low dose losartan, spironolactone, metoprolol, and digoxin. EF improved to 38% at discharge. CT angio of the head/neck/abdomen/pelvis 1 month later confirmed diagnosis of isolated abdominopelvic FMD. 2 months post discharge, our patient was walking 6 blocks thrice daily and participating in cardiac rehab (NYHA I/no angina). Discussion: This case extends our rapidly evolving understanding of cardiogenic shock due to SCAD, which often has a morbid course in the peripartum period and when the left main artery is involved. Impella support for cardiogenic shock became available in 2008 but is rarely used in SCAD management (<100 cases reported). While SCAD recognition has improved, optimal management of cardiogenic shock secondary to SCAD is undefined and may require revascularization and/or mechanical circulatory support, inotropes, or advanced heart failure therapy consideration. Our patient’s ability to wean off Impella support and inotropes prior to discharge raises the question if Impella support alone could temporize cardiogenic shock due to SCAD in lieu of Impella support combined with operative management. Further research is needed to define best practices for management of cardiogenic shock due to SCAD.