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Spontaneous coronary artery dissection in puerperium is uncommon and most often occurs in the third trimester of pregnancy and in the early postpartum period. Two weeks after delivery, a 41-year-old woman presented with typical retrosternal chest pain and inverted T-waves in leads II, V5 and V6, and Q-waves in aVR. Her peak troponin I level was 16.39 µgċL(-1) Coronary angiography showed left main spiral dissection extending to the mid left anterior descending artery and involving the first diagonal branch. Urgent coronary artery bypass grafting was performed successfully. The mechanism and approach are discussed.

Background: With the advancement of percutaneous coronary interventions, patients are presenting to coronary artery bypass grafting (CABG) older, with several co-morbidities and with prior coronary stenting. The outcome of surgery after stenting continues to be debated. We evaluated the surgical outcome of coronary artery bypass grafting in patients with previous coronary stenting. Material and Methods: This prospective cohort study included 50 patients with previous coronary stent who underwent CABG between February 2016 and June 2017. Thirty-eight patients were males (76%), and the mean age was 57.66±8.81 years. The mean ejection fraction was 41.43±9.25%. Forty-six patients (92%) had previous one stent, and 4 patients (8%) had 2 stents. Results: Nineteen patients had in-stent restenosis (38%), and 31 patients had new lesions (62%). Seven patients had lesions distal to the site of the stent (14%).The mean cardiopulmonary bypass time was 102.66±25.34 minutes. Two patients needed an intraoperative intra-aortic pump and four in the ICU. Five patients (10%) developed acute myocardial infarction. Operative mortality occurred in 4 patients (8%); one patient (2%) had an acute renal failure. Ejection fraction at 6 months postdischarge showed an increase compared to the preoperative value (41.43±9.25%-44.78±6.99%, P= 0.013).Mortality occurred more frequently in patients with IABP and in patients who had MI and renal failure. Mortality was not associated with in-stent stenosis. Conclusions: Coronary artery bypass grafting in patients with prior coronary stenting could be associated with increased morbidity and mortality. Proper management of coronary artery disease is essential to decrease the risk of future intervention.

Background: Coronary artery bypass graft surgery (CABG) in patients with left ventricular dysfunction was associated with improved survival compared to medical treatment and coronary stenting. However, the risk of surgery is still high. We aimed to evaluate the short-term outcome of CABG in patients with an ejection fraction of ≤ 40%. Patient and Methods: Forty patients with ejection fraction (EF) ≤40% underwent CABG between December 2015 and August 2019. Patients with moderate to severe mitral regurgitation, concomitant severe liver and kidney impairment, re-operative CABG, who had concomitant procedures with CABG were excluded. The mean age was 56.72±12.44 years; 30 patients (75%) were males. Twenty-six patients (65%) were diabetics, 28 patients (70%) were hypertensive, 18 patients (45%) were dyslipidemic, 22 patients (55%) were smokers, and 4 patients (10%) were obese. The preoperative ejection fraction ranged from 20% to 40%, with a mean of 34.62% Results: The mean cardiopulmonary bypass time was 90.8 minutes, and ischemic time was 49.8 minutes. Seventeen patients (42.5%) needed inotropic support intraoperatively, and 16 patients (40%) needed an intraaortic balloon. Five patients (12.5%) had postoperative ischemia, one patient (2.5%) had re-exploration for bleeding, and one patient (2.5%) had acute renal failure. The mean ICU stay was 70.5± 45.63 hours, hospital stay was 8.9± 4 days, and three patients (7.5%) had operative mortality. After 6 months operatively, the ejection fraction improved to reach a mean value of 39.87± 5.02% compared to the preoperative ejection fraction of 32.8± 8.8%. (p<0.001) Conclusion: Coronary artery bypass grafting can be performed safely in patients with depressed left ventricular function with low short-term morbidity and mortality. CABG could lead to the improvement in the ejection fraction in patients with evidence of viable myocardium.