Spontaneous dissection of left anterior descending coronary artery in a young man.

A 22-year-old man was admitted to our emergency department with recent-onset chest pain and dyspnea. The patient had experienced chest pain 42 days earlier, and it had lasted 2 days. He smoked cigarettes, 1 pack per day for 4 years, but had no other risk factors for atherosclerosis. His electrocardiogram revealed pathologic Q waves and 2-mm ST elevations in leads V1 through V6—findings that are consistent with subacute myocardial infarction and possible aneurysm formation. Transthoracic echocardiography showed left ventricular regional wall motion abnormalities (akinesia of the apical, septal, and anterior segments), severely reduced global ejection fraction (0.20 by the Simpson method), mild ischemic mitral regurgitation, and a restrictive-type diastolic filling pattern. Coronary angiography showed a linear image consistent with coronary dissection between the proximal left anterior descending coronary artery (LAD) and the 3rd diagonal artery, with Thrombosis in Myocardial Infarction (TIMI)-III flow (Fig. 1A). The left main coronary artery (LMCA), left circumflex coronary artery (LCx), and right coronary artery were normal (Fig. 1B). Positron emission tomography showed a lack of perfusion and metabolism in the apical, anteroseptal, and septal segments and hypometabolism in the basal segments (Fig. 2). Multislice computed tomographic (MSCT) coronary angiography, which was performed to determine whether the dissection extended to the LMCA or the proximal LCx, revealed that the intimal dissection originated from the proximal LAD and continued to the level of the 3rd diagonal artery (Fig. 3A). No dissection was observed in the LMCA or the LCx (Fig. 3B). Rheumatology consultation confirmed no connective tissue disorders. The patient was discharged from the hospital on medical treatment for heart failure, and he was placed on the waiting list for cardiac transplantation. Fig. 1 Coronary angiography shows A) a linear image consistent with coronary dissection (arrows) between the proximal left anterior descending coronary artery and the 3rd diagonal artery, with Thrombosis in Myocardial Infarction (TIMI)-III flow. B) Another ... Fig. 2 Positron emission tomography with 18fluorodeoxyglucose reveals a lack of perfusion and metabolism in the A) apical, septal, and anterolateral segments and hypometabolism in the basal segments. Additional views show nonviable myocardial tissue in ... Fig. 3 Multislice computed tomographic coronary angiography reveals A) the intimal dissection (arrows) originating from the proximal left anterior descending coronary artery and continuing to the level of the 3rd diagonal artery. B) Another view of the ...