Morosato Michele, Gaspardone Carlo, Romagnolo Davide, Pagnesi Matteo, Baldetti Luca, Dormio Sara, Federico Francesco, Scandroglio Anna Mara, Chieffo Alaide, Godino Cosmo, Margonato Alberto, Adamo Marianna, Metra Marco, Tchetche Didier, Dumonteil Nicolas, Tweet Marysia S, Saw Jacqueline, Beneduce Alessandro
Vita-Salute San Raffaele University, Milan, Italy.
Cardiology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy.
JACC Cardiovasc Interv. 2025 Apr 28;18(8):975-983. doi: 10.1016/j.jcin.2025.01.427. Epub 2025 Apr 9.
Spontaneous coronary artery dissection (SCAD) is an uncommon cause of acute myocardial infarction (MI) and is associated with substantial adverse events. SCAD involving the left main coronary artery (LM) is a rare but potentially life-threatening condition. Currently, minimal data on LM SCAD have been reported.
The aim of this study was to investigate clinical features, contemporary management, and clinical outcomes of patients with LM SCAD.
A systematic review and pooled analysis of published case reports was conducted using "left main" and "dissection" as keywords. The authors screened 1,106 papers in MEDLINE and Embase published between 1990 and 2023.
The final analysis included 132 patients (mean age 40 ± 11 years, 80% women) diagnosed with LM SCAD. Remarkably, 36% of cases occurred during pregnancy, and 95% presented with acute coronary syndrome, 22% with cardiogenic shock, and 8% with ventricular arrhythmias. At 120-day median follow-up, all-cause death occurred in 9%, left ventricular assist device implantation or heart transplantation in 4%, recurrent MI in 13%, and urgent myocardial revascularization (MR) in 21%. Compared with conservative management, early revascularization by percutaneous coronary intervention or coronary artery bypass grafting significantly reduced the composite endpoint of all-cause death, left ventricular assist device implantation or heart transplantation, recurrent MI, and urgent MR (adjusted HR: 0.37; 95% CI: 0.20-0.69; P < 0.001).
LM SCAD carried significant acute morbidity and mortality. Early revascularization (percutaneous coronary intervention or coronary artery bypass graft) was associated with a lower incidence of early adverse outcomes compared with conservative management, driven largely by reduction in recurrent MI and urgent MR. These hypothesis-generating data should be confirmed in future prospective registries and clinical trials.
自发性冠状动脉夹层（SCAD）是急性心肌梗死（MI）的一种罕见病因，且与大量不良事件相关。累及左主干冠状动脉（LM）的SCAD是一种罕见但可能危及生命的情况。目前，关于左主干SCAD的报道数据极少。
本研究旨在调查左主干SCAD患者的临床特征、当代治疗方法及临床结局。
以“左主干”和“夹层”作为关键词，对已发表的病例报告进行系统回顾和汇总分析。作者检索了1990年至2023年期间发表在MEDLINE和Embase上的1106篇论文。
最终分析纳入了132例被诊断为左主干SCAD的患者（平均年龄40±11岁，80%为女性）。值得注意的是，36%的病例发生在孕期，95%表现为急性冠状动脉综合征，22%表现为心源性休克，8%表现为室性心律失常。在120天的中位随访期内，全因死亡发生率为9%，左心室辅助装置植入或心脏移植发生率为4%，再发心肌梗死发生率为13%，紧急心肌血运重建（MR）发生率为21%。与保守治疗相比，经皮冠状动脉介入治疗或冠状动脉旁路移植术进行早期血运重建显著降低了全因死亡、左心室辅助装置植入或心脏移植、再发心肌梗死和紧急MR的复合终点（校正风险比：0.37；95%置信区间：0.20 - 0.69；P < 0.001）。
左主干SCAD具有显著的急性发病率和死亡率。与保守治疗相比，早期血运重建（经皮冠状动脉介入治疗或冠状动脉旁路移植术）与早期不良结局发生率较低相关，这主要是由于再发心肌梗死和紧急MR的减少。这些产生假设的数据应在未来的前瞻性登记研究和临床试验中得到证实。
