Acute Myocardial Infarction due to Coronary Artery Embolism in a Patient with Mechanical Aortic Valve Prosthesis

Coronary embolism due to probable clinical bioprosthetic aortic valve thrombosis: a case report

BACKGROUND

Coronary embolism is a relatively rare but important non-atherosclerotic cause of acute coronary syndrome, mainly caused by atrial fibrillation and mechanical heart valve thrombosis due to subtherapeutic anticoagulation. There have been increasing reports of bioprosthetic valve thrombosis (BPVT), but thromboembolic events are rare and mainly affect the cerebrovascular system. Coronary embolism is an extremely rare complication of BPVT.

CASE PRESENTATION

A 64-year-old male presented with non-ST-Elevation myocardial infarction (NSTEMI) to an Australian regional health service. Three years ago, he had undergone Bentall procedure with bioprosthetic aortic valve replacement for severe aortic regurgitation and significant aortic root dilatation. Diagnostic coronary angiography revealed embolic occlusion of first diagonal branch in the absence of underlying atherosclerosis. Prior to NSTEMI presentation, the patient was clinically asymptomatic apart from the progressive increase in transaortic mean pressure gradient on transthoracic echocardiography which was first detected seven months after surgical aortic valve replacement. Transoesophageal echocardiography showed restrictions of the aortic leaflet opening but no evidence of mass or vegetation. After eight weeks of warfarin therapy, the raised aortic valve gradient returned to normal. Lifelong warfarin was prescribed, and patient remained clinically well at 39-month follow-up.

CONCLUSION

We experienced a case of coronary embolism in a patient with probable BPVT. Reversible bioprosthetic valve hemodynamic deterioration after anticoagulation strongly supports the diagnosis in the absence of histopathology. Early moderate-to-severe hemodynamic valve deterioration warrants further investigations, including cardiac computed tomography and sequential echocardiography, to investigate for probable BPVT and consideration of timely anticoagulation initiation to prevent thromboembolic events.

A Ghost in Coronary Artery - Coronary Artery Embolism After Discontinuation of Rivaroxaban in a Patient With Atrial Fibrillation: Case Report and Review of Literature

Coronary artery embolism (CAE) is a rare clinical entity that can cause acute myocardial infarction (AMI). The exact prevalence of coronary artery embolism is unknown. CAE was found to be associated with conditions that can lead to thrombo-embolism, including infective endocarditis, atrial fibrillation, mitral valve disease, valve surgery. Herein, we report a 78-year-old male with a past medical history of atrial fibrillation on rivaroxaban who presented to the hospital emergency department complaining of chest pain. The patient's anticoagulation therapy was recently held due to a concern for gastrointestinal bleeding. After further evaluation of the patient's symptoms and reviewing his electrocardiogram (ECG) which showed ST-depression in lateral leads and ST-elevation in aVR, urgent cardiac catheterization was done which showed left main coronary artery thrombosis extending into the left anterior descending artery (LAD) and left circumflex artery (LCX). The patient was started on a heparin drip and underwent a successful aspiration thrombectomy with subsequent improvement in his symptoms.

Clinical features and prognosis of acute myocardial infarction caused by non-tumor origin coronary artery embolism

BACKGROUND

Several studies have indicated that acute myocardial infarction (AMI) secondary to coronary artery embolism (CE) has a poor prognosis. However, in the latter studies, CE of tumor origin accounts for a considerable proportion of cases and the clinical features and contribution to overall prognosis of non-tumor CE are unknown and therefore the subject of this study.

METHODS

We retrospectively studied 2006 consecutive patients with AMI at our medical center from January 2014 to October 2018. Non-tumor CE was diagnosed based on angiographic, biochemical, and imaging criteria. Patients were divided into two groups: patients without CE (control) and patients with non-tumor CE.

RESULTS

Atrial fibrillation was the most frequent etiology (n = 32, 69.6%) in the non-tumor CE group (n = 46). Compared with the control group, the non-tumor CE group had (all p < 0.05): higher incidence of atrial fibrillation; larger left atrial diameter, left ventricular end-diastolic diameter and left ventricular end-systolic diameter; lower left ventricular ejection fraction, ST-segment-elevation myocardial infarction incidence and low density lipoprotein cholesterol level; lower incidence of multivessel coronary stenosis, level of culprit lesion stenosis and proportion of angioplasty; higher ratio of manual thrombectomy and antithrombotic drugs alone therapy; lower thrombolysis in myocardial infarction (TIMI) grade and higher corrected TIMI frame counts (CTFC) after reperfusion; and statistically similar overall survival at median 864 (interquartile range, 413-1272) days.

CONCLUSIONS

The overall incidence of non-tumor CE was 2.3%, with atrial fibrillation as its most common etiology. Midterm overall survival was similar between AMI patients secondary to non-tumor CE and those without CE.

Acute coronary syndrome in an adolescent with aortic root replacement (Bentall)

Acute coronary syndrome is a cause of cardiac-induced chest pain and rarely seen among childhood. It should be kept in mind in patients presenting with typical chest pain with a history of CHD and/or surgery, as this will lead to life-threatening complications and death. We present an adolescent with a history of Bentall operation who had acute coronary syndrome owing to coronary thrombosis as a result of inappropriate drug use.

Coronary Embolism and Myocardial Infarction: A Scoping Study

Coronary embolism is a cause of acute myocardial infarction (AMI)in which obstructive foci enter the coronary circulation, block normal blood flow and precipitate ischemia. Precise studies focusing on patient population affected, pathophysiological mechanisms, and treatment strategies are scanty, in spite of a reported prevalence estimated at 2.9%. As the understanding of myocardial infarction without evidence of coronary artery disease continues to grow, an in-depth review of this previously seldomly reported subtype of coronary ischemia was in order. Patients suffering coronary embolism are 15 to 20 years younger than traditional AMI patients with a slight predominance towards male sex, which resembles the gender data of the populations affected by non-traditional myocardial infarction in published reports. While the expected prevalence rate of cardiovascular disease risk factors such as hypertension and hyperlipidemia are present, this population also has a relatively high prevalence of atrial fibrillation and valve pathology, especially endocarditis. Initial presentation is indistinguishable from other causes of myocardial infarction however fever is commonly present, when endocarditis with valvular involvement is the primary cause of the coronary embolism. Mechanical thrombectomy is the mainstay of treatment, followed by percutaneous coronary intervention. Mortality is the highest in patients who do not receive targeted treatment for the coronary embolism, particularly if only antimicrobial agents or anticoagulation without thrombolytic agents are employed. The unique features of coronary embolism highlighted in this historical study justify further examination in contemporary patient populations.

Evaluation of thrombotic left main coronary artery occlusions; old problem, different treatment approaches

Thrombotic left main coronary artery (LMCA) occlusions usually manifest as acute coronary syndrome (ACS) with cardiogenic shock, acute pulmonary edema, cardiac arrest, fatal arrhythmias or sudden cardiac death. There is no clinically predictor for LMCA thrombosis and no consensus regarding the optimal treatment. In the current literature, treatment options include emergency coronary artery bypass grafting (CABG), stent implantation, intracoronary thrombolysis, anticoagulation with heparin or glycoprotein IIb/IIIa inhibitors, thrombus aspiration as reperfusion strategies. Recently, successful results have been reported with low dose, slow infusion tPA for treatment of LMCA thrombus that allowing coronary flow. This regime may be a new treatment idea in only hemodynamically stable patients. Prospective studies and common consensus are needed about the low dose, slow infusion tPA treatment regime and optimal treatment for thrombotic LMCA obstructions.

Rare case of myocardial infarction in a 19-year-old caused by a paradoxical coronary artery embolism

This case focuses on a 19-year-old man who developed an inferior ST-segment elevation myocardial infarction as a result of a previously undetected large atrial septal defect. This cardiac anomaly facilitated the transport of a paradoxical embolism that occluded the right coronary artery.