CONGRESS ABSTRACT

A 62-year-old woman presented to the emergency department complaining of chest pain. She had an history of previous spontaneous coronary artery dissection (SCAD) of the circumflex coronary artery. At that time the transthoracic echocardiogram (TE) showed no regional wall motion abnormalities, and a mitral valve prolapse with moderate regurgitation. She underwent also a cardiac magnetic resonance (CMR) showing a small area of late gadolinium enhancement (LGE) in the mid segment of the infero-lateral wall. At the time of admission, the physical examination was unremarkable except for a 2/6 systolic murmur. The electrocardiogram showed a sinus rhythm with aspecifics ventricular repolarization alterations and laboratory test showed a troponin rise.The patient was admitted to the cardiology department with a diagnosis of suspected acute coronary syndrome. The TE was unchanged. A new coronary angiography (CA) was performed without detecting any coronary artery lesions.Given the myocardial infarction with non-obstructive coronary arteries (MINOCA) working diagnosis the patient was therefore investigated with an CMR.The exam detected a new area of transmural LGE with edema, a finding consistent with a new ischemic injury on the right coronary artery territory (RCA). Given the CMR report and the history, the new CA was retrospectively compared with the latter, allowing to highlight the presence of a microdissection in a small branch of the posterior descendent coronary artery. Therefore, the diagnosis of relapse of SCAD was made. Given the small size of the branch and the absence of angina recurrence, the patient underwent a conservative strategy with medical therapy.She was discharged after 7 days of clinical observation and elective screening of extracardiac vascular district was programmed. During the follow up no others clinical events was reported.Spontaneous coronary dissection is a rare cause of acute coronary syndrome. The identification of the underlying etiology is essential to avoid unnecessary and potentially harmful therapy and to prevent recurrence.CA is the gold standard of diagnosis. However sometimes the identification of dissection of small vessels could be challenging. Multimodality imaging could be helpful identifying doubtful cases. Indeed, in our case, CMR has a pivotal role to localize and characterize the myocardial lesion allowing us to increase the diagnostic yield of the CA focusing our attention on the right coronary artery territory.