Author + information
- Ricardo Sanz-Ruiz, MD∗ (, )
- Felipe Díez-Delhoyo, MD,
- Enrique Gutiérrez-Ibañes, MD, PhD,
- Fernando Sarnago-Cebada, MD,
- Allan Rivera-Juárez, MD,
- Jaime Elízaga-Corrales, MD, PhD and
- Francisco Fernández-Avilés, MD, PhD
- ↵∗Department of Cardiology, Hospital General Universitario Gregorio Marañón, Dr. Esquerdo, 46, Madrid 28007, Spain
We have read with great attention the letter written by Dr. Macaya and colleagues following our recently published case of spontaneous coronary artery dissection (SCAD) (1). First, we would like to thank them for their interest in our article. Second, we agree that early invasive re-evaluations need to be fully justified. Our patient had no definite ischemic symptoms nor hemodynamic or arrhythmic instability before re-evaluation. However, we decided to perform the second procedure due to the large and proximal segment with type 1 dissection and patient concerns of an eventual recurrence during hospitalization (2).
We also agree that optical coherence tomography imaging entails certain risks in SCAD patients, but its pivotal value for a precise morphological coronary assessment has been indicated. We would like to remark that, during the second procedure, the right coronary artery engagement and the optical coherence tomography run were successfully performed following a meticulous technique, with no immediate complications (iatrogenic dissection, flow worsening, or flap progression) and with no traces of thrombi formation. Importantly, coronary occlusion was evident, not immediately after this procedure, but 24 h later, following an intense Valsalva effort due to physiological needs. Thus, we think that 2 unique elements did account for vessel failure.
The first element, the presence of a large segment with medial exposure and total occlusion of the true lumen from the right coronary artery ostium. The well-known thrombogenic risk of collagen/smooth muscle cells when exposed to circulating blood, and the disappearance of the medial thromboresistance such as a destruction of its architecture, are features to be considered in large type 1 SCAD. Of note, these characteristics are not invariably present in type 2 SCAD, the most frequent kind (2). The second element, the Valsalva maneuver and subsequent abrupt intrathoracic pressure variations, showed a clear temporal cause–effect relationship in our case and may have produced blood flow velocity changes and shear stress modifications in both true and false lumens.
Finally, definitive evidence on outcomes and optimal treatment strategies in SCAD patients is lacking (3). Some predictors of recurrences have been described (2), but this elusive and challenging scenario warrants further research before one can categorically state which subgroups of patients (i.e., those with large, nude medial coronary segments) may or may not benefit from early invasive or noninvasive re-assessments and interventions.
Please note: The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- 2017 American College of Cardiology Foundation
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