Successful treatment of acutely occluded left main coronary artery in a patient with an aortic valve bioprosthesis

Introduction

Flow-limiting left main coronary artery (LMCA) thrombus is a life-threatening condition, unless immediate and successful treatment is undertaken.
We present a case of a patient with large thrombus formation within the LMCA, which occurred one day after diagnostic coronary angiography.

Case report

The 63-year-old male patient was hospitalized due to non-ST elevation myocardial infarction. His previous history included aortic valve replacement with bioprosthesis implantation and saphenous vein graft (SVG) bypass to the right coronary artery (RCA) 2 years ago, diabetes mellitus type II, previous thrombophlebitis and arterial hypertension.
The current pharmacological treatment included bisoprolol, angiotensin-converting enzyme inhibitors (ACE-I), aspirin and statin. A loading dose (600 mg) of clopidogrel was administered before admission to the hospital.
Echocardiography examination showed a well-functioning aortic bioprosthesis, preserved left ventricle ejection fraction and mild left ventricle wall hypertrophy.
Troponin level on admission was slightly elevated to 0.11 ng/ml (ULN 0.014 ng/ml).
The angiography demonstrated trifurcation of the LMCA with borderline lesions in the left coronary artery (Figures 1 A, B), and a borderline lesion in the proximal segment of the RCA with competitive flow to its distal segment from both the native RCA and patent SVG (Figures 1 C, D).
One day after the catheterization and just before planned discharge, the patient developed acute chest pain with signs of cardiogenic shock. ECG showed ST-segment elevation in I, aVL, aVR and V4–V6 leads with concomitant right bundle branch block and left anterior hemiblock (Figure 2 E).
Immediate (within 10 min), repeated angiography revealed a large thrombus within the LMCA, almost totally filling the lumen with TIMI 2 flow downstream in the main epicardial arteries (Figures 2 A, B). Abciximab and a loading dose of ticagrelor were administered. Despite several passages of manual thrombectomy, LMCA patency was not improved. Thus, percutaneous coronary intervention (PCI) with implantation of two everolimus-eluting stents (3.5 × 20 mm and 4.0 × 12 mm) into the LMCA and ostium of the intermediate branch (InB) was performed. A good angiographic result in the LMCA was achieved. The patient’s haemodynamic status improved and ECG normalized (Figure 2 F). Taking into account the given contrast amount and stabilized...


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