Coronary Artery Embolism: Two Case Reports and a Review of the Literature

Typical clinical presentation of acute myocardial infarction and confusing coronary angiography: A case report and literature review of coronary embolism

RATIONALE

The purpose of this article is to discuss the characteristics, diagnosis, treatment, and outcomes of cases of multiple coronary embolism (CE) highly suspected to be caused by a dislodged aneurysm of the ventricular membranous septum (AVMS) thrombus.

PATIENT CONCERNS

A 35-year-old man was rushed to the Chest Pain Center of Taicang TCM Hospital Affiliated to Nanjing University of Chinese Medicine for sudden onset of chest pain. The patient had severe and persistent chest pain without relief, accompanied by sweating throughout the body.

DIAGNOSIS

An electrocardiogram showed ST-segment elevation in the inferior wall leads, and blood tests suggested elevated troponin I levels. The initial diagnosis was acute ST-segment elevation myocardial infarction. Emergency coronary angiography revealed complete occlusion of the first diagonal branch, thrombolysis in myocardial infarction grade 0 flow, and smooth remaining vessels. Complete occlusion of the left anterior descending artery unexpectedly occurred during interventional treatment. Postoperative cardiac ultrasonography revealed the presence of a thrombus within the AVMS and in the apical portion of the heart. The final diagnosis was a CE.

INTERVENTIONS

Intraoperatively, the diagonal branch occluded segment was dilated with a balloon and intracoronary administration of tirofiban and nitroglycerin. Postoperatively, antithrombotic therapy (aspirin, clopidogrel, and rivaroxaban) was administered.

OUTCOMES

Ten days after admission, a repeat coronary angiography showed complete restoration of left anterior descending artery flow on its own, balloon dilation was again performed on the diagonal branch, and flow was restored to thrombolysis in myocardial infarction grade 1. Six months later, the intracardiac thrombus disappeared on repeat cardiac ultrasound.

LESSONS

AVMS is a potential source of embolism in patients with CE. CE has features that distinguish it from atherosclerosis, and a timely and correct diagnosis can help improve patient clinical outcomes.

Acute Nonatherosclerotic Coronary Thromboembolism Presenting with an Inferior STEMI in a Patient on Oral Contraception

BACKGROUND

Direct coronary embolism in the setting of oral contraceptive pill (OCP) use is a rare adverse effect. It is known for OCP to increase the risk of thrombosis; however, leading to an inferior ST elevated myocardial infarction (STEMI) due to an acute occlusive embolism is a rare entity. Coronary embolism occurs in about 3% of patients with acute coronary syndrome. Case Report. We present a case of a young 41-year-old female with a past medical history significant for dysfunctional uterine bleeding on oral contraceptive pills, who presented to the hospital with chest pain. Her workup was significant for troponin elevation and an electrocardiogram showing inferior ST elevations. The patient was taken emergently to the cardiac catheterization lab. A coronary angiogram revealed a coronary thrombus involving the distal left main and proximal left anterior descending (LAD) with no evidence of atherosclerotic disease. The patient subsequently received anticoagulation therapy leading to complete resolution of symptoms and ST elevations.

CONCLUSION

Coronary embolism is rare and often not considered in the differential of acute coronary syndrome. It is of utmost importance for clinicians to keep a wide differential of nonatherosclerotic causes of STEMI especially when the patient is young, without significant cardiac risk factors.

Embolic myocardial infarction. Literature review and own research results

Patients with embolic myocardial infarction (MI) represent a high-risk group and, accordingly, require special attention of clinicians. This article discusses the most common causes of MI, related diagnostic criteria, antithrombotic therapy, and myocardial revascularization in this category of patients. The data of own clinical experience are also given.

Acute myocardial infarction in a young woman: Unexpected findings of a coronary occlusion

In clinical and forensic practice, the cause of death is often attributed to acute myocardial infarction, among which the coronary atherosclerosis being the Captain of the Men of Death. However, other reasons such as coronary septic embolization with neutrophilic granulocyte myocarditis although rare, can also cause sudden unexpected death. This paper reports a case with this rare cause-a 21-year-old woman diagnosed with "acute gastroenteritis" who died 4 days later. A forensic autopsy revealed an inflammatory polypous embolic located at 1.0 cm from the left anterior descending branch (LAD) with serve neutrophilic granulocyte myocarditis, which resulted in embolic at the opening of the left main coronary artery, acute myocardial infarction and eventually leading to her death. Histopathological examination showed large amounts of neutrophilic granulocyte infiltration in the arterial layer forming the septic embolic and eventually resulting in coronary occlusion. To find the real cause of septic embolic, myocarditis, bacterial, fungal, protozoan and virus detection was performed through RT-PCR, with negative findings. Septic embolic leading coronary occlusion in left main coronary artery and LAD is rarely reported in forensic practice, we hope this report can pave the way on understanding this rare disease to make correct diagnosis in medical practice.