Acute inferior myocardial infarction caused by the embolization in the distal left anterior descending artery from the thrombus in the left main treated successfully without percutaneous coronary intervetion

Nemanja Djenić; Branko Milovanović; Radoslav  Romanović; Siniša  Stojković; Andjelko Hladiš; Marijan   Spasić; Boris   Džudović; Dragan   Dulović; Zoran  Jović; Slobodan   Obradović

doi:10.2298/VSP210428017D

Nemanja Djenić Military Medical Academy, Clinic for Emergency Internal Medicine, Belgrade, Serbia; University of Defence, Faculty of Medicine of the Military Medical Academy, Belgrade, Serbia
Branko Milovanović Military Medical Academy, Clinic for Emergency Internal Medicine, Belgrade, Serbia; University of Defence, Faculty of Medicine of the Military Medical Academy, Belgrade, Serbia
Radoslav Romanović Military Medical Academy, Clinic for Emergency Internal Medicine, Belgrade, Serbia; University of Defence, Faculty of Medicine of the Military Medical Academy, Belgrade
Siniša Stojković University Clinical Center of Serbia, Clinic for Cardiology, Belgrade, Serbia; University of Belgrade, Faculty of Medicine, Belgrade, Serbia
Andjelko Hladiš Military Medical Academy, Clinic for Emergency Internal Medicine, Belgrade, Serbia
Marijan Spasić Military Medical Academy, Clinic for Emergency Internal Medicine, Belgrade, Serbia
Boris Džudović Military Medical Academy, Clinic for Emergency Internal Medicine, Belgrade, Serbia
Dragan Dulović Military Medical Academy, Clinic for Emergency Internal Medicine, Belgrade, Serbia; University of Defence, Faculty of Medicine of the Military Medical Academy, Belgrade, Serbia;
Zoran Jović Military Medical Academy, Clinic for Emergency Internal Medicine, Belgrade, Serbia; University of Defence, Faculty of Medicine of the Military Medical Academy, Belgrade, Serbia
Slobodan Obradović Military Medical Academy, Clinic for Emergency Internal Medicine, Belgrade, Serbia; University of Defence, Faculty of Medicine of the Military Medical Academy, Belgrade, Serbia

DOI: https://doi.org/10.2298/VSP210428017D

Keywords: coronary artery disease;, coronary vessels;, myocardial infarction;, platelet aggregation inhibitors;, treatment outcome

Abstract

Introduction. The left main stem (MS) coronary artery (CA) (MSCA) thrombosis is a rare but potentially lethal manifestation of acute coronary syndrome. The standard approach in treating such patients is the primary percutaneous coronary intervention (pPCI) or CA bypass graft surgery. In some cases, depending on the morphological appearance of the thrombus, findings and flow rates assessed on coronary angiography (CAn), clinical conditions, and cardiologist’s experiences, another possible method of treatment can be the conservative approach using antithrombotic therapy. Case report. A 37-year-old male was admitted to the emergency room with symptoms of an acute myocardial infarction with an ST elevation in diaphragmal localization. Using an emergency CAn, we have visualized a thrombus at the ostial and proximal part of the left MSCA, with no complete obstruction of the blood flow. Initially, dual antithrombotic therapy (ticagrelor and acetylsalicylic acid) was applied, and in the further procedure, it was decided to introduce glycoprotein IIb/IIIa platelet receptor inhibitor (tirofiban) as an intracoronary bolus (0.3 µg/kg) and later as a continuous infusion (0.1 µg/kg/min). Four days later, a control CAn and intravascular echocardiography were performed, and it was decided to continue the treatment using conservative therapy without a pPCI procedure. The patient was discharged in good condition with no signs of illness on the eighth day after hospital admission for home recovery, with planned frequent follow-ups in the future. Conclusion. In the case of non-obstructive thrombotic masses without significant atherosclerotic stenotic lesions, conservative treatment modality with the use of aggressive antithrombotic therapy may be considered.

References

Bentzon JF, Otsuka F, Virmani R, Falk E. Mechanisms of plaque formation and rupture. Circ Res 2014; 114(12): 1852‒66.

Lee MS, Dahodwala MQ. Percutaneous coronary intervention for acute myocardial infarction due to unprotected left main coronary artery occlusion: status update 2014. Catheter Car-diovasc Interv 2015; 85(3): 416‒20.

Arora NP, Joumaa M, Rosman H, Mehta R. Left Main Coronary Artery Thrombosis with Acute Myocardial Infarction: A Man-agement Dilemma. Am J Med Sci 2017; 353(6): 597‒602.

Mahmoudi M, Delhaye C, Wakabayashi K, Torguson R, Xue Z, Suddath WO, et al. Integrilin in patients undergoing primary percutaneous coronary intervention for ST-elevation myocar-dial infarction. J Interv Cardiol 2011; 24(4): 351‒6.

Shah I, Khan SO, Malhotra S, Fischell T. Eptifibatide: the evi-dence for its role in the management of acute coronary syn-dromes. Core Evid 2010; 4: 49–65. Erratum in: Core Evid 2014; 9: 49.

Akcay M. Evaluation of thrombotic left main coronary artery occlusions; old problem, different treatment approaches. Indi-an Heart J 2018; 70(4): 573‒4.

Patel M, Bhangoo M, Prasad A. Successful percutaneous treat-ment of suspected embolic left main thrombosis in a patient with a mechanical aortic valve. J Invasive Cardiol 2011; 23(11): E263–6.

Grion DDS, Grion DC, Silverio IV, Oliveira LS, Larini IF, Mar-tins AV, et al. Percutaneous Coronary Intervention in Unpro-tected Left Main Coronary Artery Lesions. Arq Bras Cardiol 2021; 116(6): 1101‒8. (English, Portuguese)

Ali M, Becker RC. Bridging Anticoagulation with Mechanical Heart Valves: Current Guidelines and Clinical Decisions. Curr Cardiol Rep 2020; 22(11): 130.

Hudec S, Hutyra M, Precek J, Latal J, Nykl R, Spacek M, et al. Acute myocardial infarction, intraventricular thrombus and risk of systemic embolism. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2020; 164(1): 34‒42.

Kappetein AP, Head SJ, Osnabrugge RL, van Mieghem NM. Role of percutaneous coronary intervention in the treatment of left main coronary artery disease. Semin Thorac Cardiovasc Surg 2014; 26(3): 187‒91.

Apostolakis E, Tsigkas G, Baikoussis NG, Koniari I, Alexopoulos D. Acute left main coronary artery thrombosis due to cocaine use. J Cardiothorac Surg 2010; 5: 65.

Olcay A. Concomitant left main coronary artery and prosthetic mitral valve thrombosis treatment. Anatol J Cardiol 2018; 20(6): 365‒7.

Vinod VC, Yousif ZE, Salim NO, Majwal T. Proximal Left Main Coronary Artery Aneurysm Presenting as ST-Elevation Myocardial Infarction Treated by Stenting. Case Rep Cardiol 2020; 2020: 8833917.

Dunn S, Dave N, Rodriguez-Blanco YF, Aljure O. Incidental find-ing of a left atrial thrombus during surgical management of a massive pulmonary embolism. Ann Card Anaesth 2020; 23(1): 87‒9.

Thomopoulou S, Sfirakis P, Spargias K. Angioplasty, stenting and thrombectomy to correct left main coronary stem obstruction by a bioprosthetic aortic valve. J Invasive Cardiol 2008; 20(4): E124–5.

Ayari J, Mourali MS, Farhati A, Mechmeche R. Left main coro-nary artery thrombosis revealing angio-Behçet syndrome. Egypt J Intern Med 2014; 26(2): 88‒90.

Sanchez-Recalde A, Calvo Orbe L, Galeote G. Cardiogenic shock due to complete thrombotic occlusion of the left main coro-nary ostium in a young female. J Invasive Cardiol 2006; 18(6): E188–90.

Fajadet J, Chieffo A. Current management of left main coro-nary artery disease. Eur Heart J 2012; 33(1): 36–50b.

Choi J, Kim IS, Cho S, Kim JS, Hong SJ, Shin DH, et al. Optimal Duration for Dual Antiplatelet Therapy After Left Main Cor-onary Artery Stenting. Circ J 2020; 85(1): 59‒68.

Chandrasekhar J, Baber U, Sartori S, Aquino M, Tomey M, Kruckoff M, et al. Patterns and associations between DAPT cessation and 2-year clinical outcomes in left main/proximal LAD versus other PCI: Results from the Patterns of Non-Adherence to Dual Antiplatelet Therapy in Stented Patients (PARIS) registry. Int J Cardiol 2017; 243: 132‒9.

Lee HJ, Yu CW, Hwang HK, Choi RK, Park JS, Li H, et al. Long-term effectiveness and safety of triple versus dual an-tiplatelet therapy after percutaneous coronary intervention for unprotected left main coronary artery disease. Coron Artery Dis 2013; 24(7): 542‒8.

Sarma J, Laan CA, Alam S, Jha A, Fox KA, Dransfield I. In-creased platelet binding to circulating monocytes in acute cor-onary syndromes. Circulation 2002; 105(18): 2166–71.

Collet JP, Thiele H, Barbato E, Barthélémy O, Bauersachs J, Bhatt DL, et al. 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J 2021; 42(14): 1289–367.