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 Table of Contents  
INTERESTING CASE REPORT
Year : 2020  |  Volume : 4  |  Issue : 1  |  Page : 39-41

Embolic ST-segment elevation myocardial infarction following aortic prosthetic valve replacement: Diagnosis and management issues


Institute of Cardiology, Madras Medical College, Chennai, Tamil Nadu, India

Date of Submission23-May-2019
Date of Decision05-Jan-2020
Date of Acceptance27-Jan-2020
Date of Web Publication11-Apr-2020

Correspondence Address:
Dr. Deepak R. Nenwani
Room No. 115, MMC Men's Hostel, Near Broadway Bus Stand, Opposite to Tamil Nadu Public Service Commission Office, Chennai - 600 003, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiae.jiae_26_19

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  Abstract 


Acute thromboembolism resulting in ST-segment elevation myocardial infarction years after aortic valve replacement (AVR) is an uncommon occurrence. 38 years old female admitted with chest pain of 8 hours duration. Patient had history of Aortic valve replacement 3 years. Patient on evaluation found to have infero-lateral wall myocardial infarction. Coronary angiography (CAG) was done, which showed occlusive thrombus in the left coronary artery. The left circumflex artery after second obtuse marginal branch had total occlusion, and distal left anterior descending had total occlusion with thrombus containing lesion, whereas the right coronary artery was normal. The patient was thrombolyzed with intravenous streptokinase 1.5 mIU over 30 min infusion with door-to-needle time of 75 min. Pre- and postprocedure echocardiogram showed no evidence of thrombus. Gradient across the aortic valve and mobility was within the normal limits. Check CAG after 7 days showed resolution of thrombus burden in coronaries.

Keywords: Aortic valve replacement, coronary embolism, rare case, ST-segment elevation myocardial infarction, tilting disc metallic valve


How to cite this article:
Nenwani DR, Kumaran MN, Venkatesan S, Elangovan C, Nageshwaran PM, Majella J C. Embolic ST-segment elevation myocardial infarction following aortic prosthetic valve replacement: Diagnosis and management issues. J Indian Acad Echocardiogr Cardiovasc Imaging 2020;4:39-41

How to cite this URL:
Nenwani DR, Kumaran MN, Venkatesan S, Elangovan C, Nageshwaran PM, Majella J C. Embolic ST-segment elevation myocardial infarction following aortic prosthetic valve replacement: Diagnosis and management issues. J Indian Acad Echocardiogr Cardiovasc Imaging [serial online] 2020 [cited 2020 Aug 13];4:39-41. Available from: http://www.jiaecho.org/text.asp?2020/4/1/39/282199




  Introduction Top


Acute thromboembolism resulting in ST-segment elevation myocardial infarction years after aortic valve replacement (AVR) is an uncommon occurrence.[1],[2] Here, we report the case of a 38-year-old female presenting with inferolateral wall myocardial infarction, who underwent mechanical AVR 3 years back.[3],[4]


  Clinical Presentation Top


A 38-year-old female presented in the emergency room with chief complaints of chest pain of 8 hours (h) duration. Chest pain was typically associated with sweating and palpitation. The patient had undergone surgery for aortic valve replacement with TTK Chitra valve (25 mm) for severe aortic regurgitation 2 year's back. The patient was taking tab Acitrom 2 mg daily for mechanical prosthetic aortic valve. The patient had no prior history of diabetes mellitus/hypertension/dyslipidemia/coronary artery disease/chronic kidney disease. The patient had no history of fever/black stools. The patient's last INR test done 3 months back was 1.04. Electrocardiogram done showed ST elevation in II, III, aVF lead, right bundle branch block, and ST depression in V1–V3 [Figure 1]a and [Figure 1]b. Echo done was suggestive of hypokinesia of inferior segment, inferoseptal, and inferolateral segment of the left ventricle, ejection fraction (EF) – 58%, normal aortic prosthetic valve position and mobility of tilting disc, aortic valve gradient (mean – 16, peak – 33), mild mitral regurgitation +, posterior mitral leaflet mobility restricted, and mitral valve orifice area 2.2 cm2. Troponin I was positive. Coronary angiography (CAG) done within 1 h of admission showed proximal left anterior descending (LAD) total cutoff with thrombus containing lesion and distal left circumflex artery (LCX) total cut-off, and right coronary artery was normal [CAG Videos 1-3]. The patient was lysed with IV streptokinase 1.5 mIU over 30 min. Thrombolysis was successful with ST-T changes settling to baseline and resolution of chest pain [Figure 2].
Figure 1: (a) ST-elevation in II, III, aVF lead, right bundle branch block, and ST-depression in V1–V3. (b) Right side electrocardiogram shows ST-elevation in V7 and V8

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Figure 2: Post-thrombolysis echocardiogram shows ST-T changes settling to baseline

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Initial laboratory parameters:

  • Hemoglobin – 8.2 g/dl, Hematocrit – 28.8%, Platelet – 3.5 lakh/mm3
  • Peripheral smear – Microcytic hypochromic anemia with eosinophilia
  • Neutrophils – 65%, Lymphocytes – 26%, Eosinophils – 9%, absolute eosinophil count – 791 (mg/dl) cells/mm3
  • Total count – 25,000/mm3
  • Random blood sugar – 128, urea – 31, creatinine – 0.6
  • Total cholesterol – 166 mg/dl, Triglyceride – 106 mg/dl, High density lipoprotein – 42 mg/dl
  • Prothrombin time – 13.2 s, INR – 1.03.


The patient was treated with medical management including anti-platelets, statins, and anticoagulants (heparin 5000 IU IV qid) for 7 days. Check CAG done after 7 days of medical management showed partial resolution of thrombus [CAG Videos 4 and 5].







Repeat echo after 5 days of admission showed no regional wall motion abnormality, ejection fraction -62%, normally functioning tilting disc prosthetic valve at aortic position, aortic valve gradient peak (29 mmHg), mean (14 mmHg) [Figure 3], and no pulmonary hypertension (Videos 6-9).
Figure 3: Normal functioning tilting disc prosthetic valve at the aortic position, gradients, peak (29 mmHg), mean (14 mmHg)

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Anticoagulant dose was up titrated, and INR was maintained between 2 and 3.

The patient was discharged and advised to follow-up in the outpatient department.


  Discussion Top


Mechanical prosthetic valves are thrombogenic, and patients who undergo mechanical valve replacement are at high risk of thrombosis and require lifelong oral anticoagulant.[5],[6] Simultaneously, these patients are at high risk of bleeding. These patients need to maintain INR value between 2 and 3.[2-5] Coronary embolism is uncommon cause of ST-segment elevation myocardial infarction (STEMI). However, there are many recent reports of STEMI in patients with a mechanical prosthetic valve with subtherapeutic INR. Other causes of coronary artery embolism are infective endocarditis, atrial thrombus in setting of atrial fibrillation, atrial myxoma, tissue embolism of prosthetic valve, calcific embolism from calcified aortic valve, and biological glue embolism used in the repair of aortic dissection.[1]

In our case, the diagnosis of coronary artery embolism is definite as classified under national cerebral and cardiovascular center criteria [Figure 4].[7] Major criteria include angiographic evidence of coronary artery embolism and thrombosis without atherosclerosis, and concomitant coronary artery embolism at multiple sites including LAD and LCX. Minor criteria include <25% stenosis on CAG. In our case, coronary embolism was due to thrombus related to mechanical aortic valve as the patient was on subtherapeutic dose of anticoagulant. The patient was not compliant to follow-up. INR documented in her last visit was 3 months back was 1.04. Thrombus was visualized well on CAG which resolved after treatment with reperfusion therapy and anticoagulation. Thrombus burden was reducing significantly in coronaries after treatment which was again confirmed with check CAG. The patient was started on oral anticoagulant, and INR was maintained between 2 and 3. The patient was discharged in a stable condition.
Figure 4: National cerebral and cardiovascular center criteria

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  Conclusion Top


Mechanical heart valves are prone to thrombus formation due to high shear stress, stagnation, and flow separation. Tilting disc valves have high shear stress as compared to other valves, and flow separation is more in tilting disc valve as compared to bileaflet valve makes tilting disc valve more prone to thrombus formation.[8] We presume that in our case, thrombus embolism preferential to the left coronary artery is due to the movement of the tilting disc toward the left coronary artery (Video 9).

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Levis JT, Schultz G, Lee PC. Acute myocardial infarction due to coronary artery embolism in a patient with a tissue aortic valve replacement. Perm J 2011;15:82-6.  Back to cited text no. 1
    
2.
Hammermeister KE, Sethi GK, Henderson WG, Oprian C, Kim T, Rahimtoola S. A comparison of outcomes in men 11 years after heart-valve replacement with a mechanical valve or bioprosthesis. Veterans affairs cooperative study on valvular heart disease. N Engl J Med 1993;328:1289-96.  Back to cited text no. 2
    
3.
Bloomfield P, Wheatley DJ, Prescott RJ, Miller HC. Twelve-year comparison of a bjork-shiley mechanical heart valve with porcine bioprostheses. N Engl J Med 1991;324:573-9.  Back to cited text no. 3
    
4.
Nakazone MA, Tavares BG, Machado MN, Maia LN. Acute myocardial infarction due to coronary artery embolism in a patient with mechanical aortic valve prosthesis. Case Rep Med 2010;2010:751857.  Back to cited text no. 4
    
5.
Tarentino AL, Maley F. A comparison of the substrate specificities of endo-beta-N-acetylglucosaminidases from Streptomyces griseus and Diplococcus pneumoniae. Biochem Biophys Res Commun 1975;67:455-62.  Back to cited text no. 5
    
6.
American College of Cardiology, American Heart Association Task Force on Practice Guidelines (Writing Committee to revise the 1998 guidelines for the management of patients with valvular heart disease), Society of Cardiovascular Anesthesiologists, Bonow RO, Carabello BA, Chatterjee K, et al. ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing Committee to Revise the 1998 guidelines for the management of patients with valvular heart disease) developed in collaboration with the Society of Cardiovascular Anesthesiologists endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons. J Am Coll Cardiol 2006;48:e1-148.  Back to cited text no. 6
    
7.
Shibata T, Kawakami S, Noguchi T, Tanaka T, Asaumi Y, Kanaya T, et al. Prevalence, clinical features, and prognosis of acute myocardial infarction attributable to coronary artery embolism. Circulation 2015;132:241-50.  Back to cited text no. 7
    
8.
Figliola RS, Mueller TJ. Stresses in the vicinity of disc, ball, tilting disc prosthetic heart valve fromin vitro measurements. J Biomech Eng 1977;99:173-7.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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