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CASE20191029_017
| CORONARY - Acute Coronary Syndromes (STEMI, NSTE-ACS) | |
| Acute Myocardial Infarction Due to Coronary Artery Embolism Whose Embolic Source Was Clearly Detected | |
| Satoshi Tasaka1 | |
| Kyoto Chubu Medical Center, Japan1, | |
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[Clinical Information]
- Patient initials or identifier number:
I.Y.
-Relevant clinical history and physical exam:
A 48-year-old previously healthy man presented to the emergency department with chest pain of sudden onset. His blood pressure was 73/49mmHg, and pulse was 46/min with a regular rhythm. No pathological heart murmur was audible and respiratory sound was clear, but he broke out into a cold sweat.
-Relevant test results prior to catheterization:
Laboratory test showed that white blood cell, creatine phosphokinase, and serum creatinine were elevated at 13,990/¥ìL, 447 IU/L, and 1.25 mg/dL, respectively. Electrocardiography showed complete atrioventricular block and an elevated ST-segment in II, III, and aVF limb leads. Echocardiogram showed diffusely reduced left ventricular wall motion (ejection fraction: 40%) and moderate tricuspid regurgitation.
- Relevant catheterization findings:
Emergency coronary angiography showed occlusion in the mid segment of the right coronary artery (RCA).
 RCA.mp4 |
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[Interventional Management]
- Procedural step:
A 7Fr Hyperion JR4 guide catheter was favorably engaged in RCA, then we passed an initial guidewire to the posterior descending coronary artery and a second guidewire to the atrioventricular branch. Aspirating thrombi and crushing them by balloon inflation recovered favorable blood flow. Optical coherence tomography demonstrated neither evidence of plaque rupture nor erosion at the culprit lesion, so we did not carry out stent deployment. Paroxysmal atrial fibrillation occurred during the hospital stay. Therefore, we performed trans esophageal echocardiography and identified a huge thrombus in the left atrial appendage (LAA). These findings indicate acute myocardial infarction caused by highly likely thromboembolism from the LAA thrombus. Direct oral anticoagulant agents were prescribed and the LAA thrombus disappeared. No thromboembolic event has since been observed.
final.mp4 OCT.mp4 TEE1.mp4- Case Summary:
Coronary artery embolism (CE) is the underlying cause of 2.9% of cases of de novo acute myocardial infarction (AMI). Considering the poorer long-term outcomes of CE patients than non-CE patients, we must recognize them as a high-risk subpopulation of AMI patients. Atrial fibrillation is the most frequent cause of CE, and the recurrence of CE and systemic thromboembolism tends to be noted in patients with atrial fibrillation. Therefore, we must appropriately diagnose CE patients and optimize management to improve their prognoses.
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