Successful management of left main coronary artery thrombus with

Türk Kardiyol Dern Arş - Arch Turk Soc Cardiol 2014;42(5):475-477 doi: 10.5543/tkda.2014.93213
475
Successful management of left main coronary artery
thrombus with intracoronary thrombolysis
Ana koroner arter trombüsünün koroner içi trombolitik uygulaması ile
başarılı tedavisi
Ufuk Gürkan, M.D., Mustafa Adem Tatlısu, M.D., Emre Aruğaslan, M.D., Osman Bolca, M.D.
Department of Cardiology, Dr. Siyami Ersek Cardiovascular Surgery Hospital, Istanbul
Summary– The management of valvular heart diseases
with mechanical valves has been performed for several
years. Warfarin has been used in patients with mechanical heart valves to protect against thromboembolic complications; nevertheless, in these patients, thromboembolic
event rates range from 0.5% to 1.7%. Acute occlusive embolism to the coronary arteries due to a mechanical valve is
an uncommon occurrence. In this report, we present a case
of a left coronary system occlusion due to thrombus embolization from a prosthetic aortic valve, which was successfully
treated by thrombolytic therapy.
T
he management of valvular heart diseases with
mechanical valves has been performed for several years. Acute occlusive embolism to the coronary
arteries due to mechanical valve continues to be seen
in our clinical practice despite the use of warfarin
therapy.
In this case report, we present a case of a left coronary system occlusion due to thrombus embolization
from a prosthetic aortic valve, which was successfully
treated with thrombolytic therapy.
CASE REPORT
A 47-year-old man, who had undergone aortic valve
replacement for rheumatic disease 11 years before,
was admitted with shortness of breath and angina
lasting about 10 hours. He underwent invasive coronary angiography due to positive electrocardiographic exercise stress testing, and epicardial coronary
Özet– Yapısal kapak hastalıklarının tedavisinde yapay mekanik kapaklar yıllardır kullanılmaktadır. Varfarin tromboembolik komplikasyonlara karşı korumak için mekanik kalp
kapağı olan hastalarda kullanılmaktadır, buna rağmen bu
hastalarda %0.5-1.7 oranında tromboembolik olaylar görülmektedir. Yapay mekanik kapağa bağlı akut tıkayıcı koroner
embolisi de nadir olarak görülmektedir. Bu yazıda, düzensiz
varfarin kullanım öyküsü olan bir hastada yapay mekanik
aort kapaktan kaynaklanan emboli sonucu gelişen yaygın
sol koroner sistem trombozu saptanan ve başarılı trombolitik uygulaması ile tedavi edilen olgu sunuldu.
arteries were angio- Abbreviations:
graphically normal. IABP Intra-aortic balloon pump
On
presentation, INR International normalized ratio
Left anterior descending
his blood pressure LAD
LMCA Left main coronary artery
was 75/55 mmHg PCI Percutaneous coronary intervention
Transesophageal echocardiogram
in the right arm and TEE
tPA
Tissue plasminogen activator
70/50 mmHg in the TTE Transthoracic echocardiogram
left arm. On physical examination, widespread fine crepitant rales
were heard over both lungs. The 12-lead electrocardiogram showed ventricular tachycardia, and
then sinus rhythm was obtained after synchronized
electrical cardioversion with 50 joules. The second
12-lead electrocardiogram showed ST-segment elevation in leads aVR and V1 through V6. The transthoracic echocardiogram (TTE) showed impaired
anterior and anterolateral wall motion and impaired
left ventricular systolic function (ejection fraction
<25%). TTE also showed a normally functioning
Received: November 16, 2013 Accepted: February 27, 2014
Correspondence: Dr. Ufuk Gürkan. Dr. Siyami Ersek Göğüs Kalp ve Damar Cerrahisi
Eğitim ve Araştırma Hastanesi, Tıbbiye Cad., No: 13, Haydarpaşa, 34668 İstanbul.
Tel: +90 216 - 542 44 44 e-mail: drufukgurkan@gmail.com
© 2014 Turkish Society of Cardiology
Türk Kardiyol Dern Arş
476
prosthetic aortic valve. Transaortic peak and mean
gradients were 18 mmHg and 9 mmHg, respectively.
Notwithstanding the high sensitivity of transesophageal echocardiogram (TEE) to evaluate prosthetic
heart valve function, TEE could not be used in this
case due to hemodynamic instability and the need
for urgent revascularization. The international normalized ratio (INR) was 0.98 at admission. He was
transferred to the catheterization laboratory immediately for primary percutaneous coronary intervention
(PCI). Intra-aortic balloon pump (IABP) was inserted for hemodynamic support. The coronary angiography revealed a massive thrombus not only in the
distal left main coronary artery (LMCA) but also at
the ostium of the left circumflex coronary artery and
intermediate branch with totally occluded left anterior descending (LAD) coronary artery (Figure 1).
Slow flow was seen in the right coronary artery. Fluoroscopy confirmed normal motion of the prosthetic
valve leaflets. Due to the widespread thrombus, we
preferred intracoronary fibrinolysis (tissue plasminogen activator, tPA) to aspiration thrombectomy. He
had no contraindication to fibrinolysis. First, 15 mg
tPA was administered into the coronary artery; then,
50 mg tPA was administered intravenously over 30
minutes; and finally, 35 mg tPA was administered intravenously over the next 60 minutes. Heparin was
administered simultaneously with tPA infusion. After 10 minutes, TIMI (Thrombolysis in Myocardial
Infarction) flow grade 3 in the LAD was seen during the second coronary angiography (Figure 2a).
Figure 1. Intracoronary thrombus in the LMCA and totally
occluded LAD with absent flow.
A
B
Figure 2. (A) Angiographic image of the LMCA and LAD
after intracoronary fibrinolysis. (B) Angiographic image of
the LMCA and LAD 24 hours after intracoronary fibrinolysis.
Reperfusion led to rapid hemodynamic improvement
and reduction in the symptoms of angina, and he was
then transferred to the coronary care unit. Resolution
of ST-segment elevation was seen 90 minutes after
thrombolysis. TEE confirmed normal prosthetic aortic valve function. IABP support was stopped, and the
third coronary angiography was performed 24 hours
after admission. Coronary angiography revealed normal coronary arteries (Figure 2b). The therapeutic
INR range (2.5-3) was achieved, and the patient was
discharged. The patient was seen one month after
discharge, and TTE revealed impaired anterior wall
motion and left ventricular systolic function (ejection fraction: 35%) and normally functioning prosthetic aortic valve.
Successful management of left main coronary artery thrombus by intracoronary thrombolysis
477
DISCUSSION
REFERENCES
Incidence of acute myocardial infarction due to a
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approximately 0.8-1.7%.[1] Cardiogenic shock most
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and subsequent thrombus formation. Other causes
reported are embolism, aortic dissection, pulmonary
artery compression, and vasospasm.[2] Our patient
had no risk factors for coronary artery disease. Due
to irregular warfarin use and ineffective INR values,
we considered embolism to the coronary artery from
the prosthetic aortic valve thrombus. Even with the
use of warfarin, incidence of major systemic embolism was found as 2% in patients with heart valve replacement.[3] Moreover, embolus to the LMCA can be
seen in patients with prosthetic heart valve without
evidence of thrombus.[1-4] Aspiration thrombectomy
was used effectively in these cases. Due to the distal
left main stem thrombus extending into the ostium of
the LAD and the intermediate vessel, we preferred intracoronary tPA to aspiration thrombectomy. With the
advances in PCI, clinical use of intracoronary thrombolytic therapy has declined steadily. However, some
publications still suggest intracoronary thrombolysis
for widespread thrombus in the LMCA.[6] In addition
to the success of thrombolytic therapy in prosthetic
heart valve thrombosis, this therapy can be chosen
in patients with left main stem thrombus.[4,7-9] In this
case, subsequent diagnostic coronary angiography
demonstrated normal coronary arteries.
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In conclusion, in the case of left main stem thrombosis, intracoronary fibrinolysis can be preferred to
aspiration thrombectomy due to the high risk of distal
embolization.
Conflict-of-interest issues regarding the authorship or
article: None declared.
Key words: Acute myocardial infarction; aortic valve, mechanical;
thrombolytic therapy/methods.
Anahtar sözcükler: Akut miyokart enfarktüsü; aort kapağı, mekanik;
trombolitik tedavi/yöntem.