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Objectives This study sought to assess the long-term clinical outcome of patients with spontaneous coronary artery dissection (SCD) managed with a conservative strategy. Background SCD is a rare, but challenging, clinical entity. Methods A prospective protocol, including a conservative management strategy, was followed. Revascularization was only considered in cases with ongoing/recurrent ischemia. Inflammatory/immunologic markers were systematically obtained. Results Forty-five consecutive patients (incidence 0.27%) were studied during a 6-year period. Of these, 27 patients (60%) had “isolated” SCD (I-SCD), and 18 had SCD associated with coronary artery disease (A-SCD). Age was 53 ± 11 years, and 26 patients were female. Most patients presented with an acute myocardial infarction. SCD had a diffuse angiographic pattern (length: 31 ± 23 mm). In 11 patients, the diagnosis was confirmed by intracoronary imaging techniques. Sixteen patients (35%) required revascularization during initial admission. One patient died after surgery, but no additional patient experienced recurrent myocardial infarction. No significant inflammatory/immunologic abnormalities were detected. At follow-up (median 730 days), only 3 patients presented with adverse events (1 died of congestive heart failure, and 2 required revascularization). No patient experienced a myocardial infarction or died suddenly. Event-free survival was similar (94% and 88%, respectively) in patients with I-SCD and A-SCD. Notably, at angiographic follow-up, spontaneous “disappearance” of the SCD image was found in 7 of 13 (54%) patients. Conclusions In this large prospective series of consecutive patients with SCD, a “conservative” therapeutic strategy provided excellent long-term prognosis. Clinical outcome was similar in patients with I-SCD and A-SCD. The natural history of SCD includes spontaneous healing with complete resolution.

ObjectivesThis study sought to assess the diagnostic value of optical coherence tomography (OCT) in patients with suspected spontaneous coronary artery dissection (SCAD).BackgroundSCAD is a rare but challenging clinical entity.MethodsFollowing a prospective protocol, OCT was performed in 17 consecutive patients with a clinical and angiographic suspicion of SCD from a total of 5,002 patients undergoing coronary angiography. A conservative management strategy was followed.ResultsOCT ruled out the diagnosis of SCAD in 6 patients with coronary artery disease (atherosclerotic plaques and/or intracoronary thrombus). In 11 patients (age 48 ± 9 years, 9 female), OCT confirmed the presence of SCAD. A double-lumen or intramural hematoma image was visualized in all cases. However, only 3 patients presented an intimal “flap” on angiography. OCT readily identified the intimal rupture site (n = 7), the thickness (348 ± 84 μm) and length (31 ± 9 mm) of the intimomedial membrane, the area of the true (1.1 ± 0.5 mm2) and false lumen (5.9 ± 2.1 mm2), the associated intramural hematoma (n = 9), and thrombi in the true or false lumens (n = 11). Most of these findings were angiographically silent. After stenting (n = 4), OCT disclosed adequate stent coverage, expansion, and apposition, but also residual intramural hematoma at the stented site (abluminal) and at the distal vessel.ConclusionsOCT provides unique insights in patients with SCAD that allow an early diagnosis and adequate management. Most of these findings are undetectable by angiography.

The echocardiographic technology known as three-dimensional wall motion tracking offers three-dimensional images of the myocardium and provides multiple measures of deformation, one of which is known as “area strain” (AS), which combines left ventricular longitudinal and circumferential deformations. Our aim was to describe the normal maximum systolic reference AS value in a sample of healthy subjects. Sixty consecutive subjects without known cardiovascular risk factors or diseases were enrolled, and left ventricular AS was measured. Overall mean AS was –38.87 ± 5.89%. Mean values at the level of the basal, middle, and apical segments were –38.42% ± 7.58%, –38.74% ± 6.34%, and −43.18% ± 12.81%, respectively. Thus, our results show for the first time the reference values for AS in healthy subjects.

Resumen La tecnologia ecocardiografica denominada three-dimensional wall motion tracking es capaz de realizar un seguimiento tridimensional del miocardio y obtener multiples valores de su deformacion, entre los que se encuentra el area strain (AS), que combina el analisis de la deformacion longitudinal y circunferencial del ventriculo izquierdo. Nuestro objetivo es describir el valor sistolico maximo normal de referencia de AS en una muestra de sujetos sanos. Se recluto a 60 sujetos consecutivos, sin enfermedad ni factores de riesgo cardiovascular conocidos, y se les cuantifico el AS del ventriculo izquierdo. El valor promedio de AS fue –38,87 ± 5,89%. Los valores promedio a nivel de los segmentos basales, medio y apicales fueron –38,42 ± 7,58%, –38,74 ± 6,34% y –43,18 ± 12,81% respectivamente. Por lo tanto, nuestros resultados muestran, por primera vez, los valores de referencia de AS en sujetos sanos.

A feasibility study Leopoldo Perez de Isla ⁎, Vera Lennie , Maribel Quezada , Juan Guinea , Cristina Arce , Pilar Abad , Adriana Saltijeral , Nellys Carolina Campos , Jacobo Crespo , Borja Gonzalvez , Agustin Macia , Jose Zamorano d a Unidad de Imagen Cardiologica, Hospital Carlos III, Madrid, Spain b Cardiologia, Hospital del Tajo, Aranjuez, Madrid, Spain c Nuubo, Madrid, Spain d Unidad de Imagen Cardiovascular, Hospital Clinico San Carlos, Madrid, Spain

We read with great interest the elegant study by Saw et al. [(1)][1] that carefully described predisposing conditions in a large Canadian series of 50 patients with spontaneous coronary artery dissection (SCAD). Notably, fibromuscular dysplasia (FMD) in noncoronary territories was found in 86% of