JACC: CARDIOVASCULAR INTERVENTIONS
VOL. 7, NO. 10, 2014
ª 2014 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION PUBLISHED BY ELSEVIER INC.
ISSN 1936-8798/$36.00 http://dx.doi.org/10.1016/j.jcin.2014.02.025
IMAGES IN INTERVENTION
Coronary Embolism and Thrombosis of Prosthetic Mitral Valve Francisco Javier Lacunza-Ruiz, MD, Carmen Muñoz-Esparza, MD, Juan García-de-Lara, MD
A
66-year-old woman was admitted to our hos-
T waves in leads V2 to V4 , not present on previous
pital with chest pain. Three months earlier,
electrocardiograms. The patient was taken emer-
she underwent implantation of a mechanical
gently to the catheterization laboratory. Angiography
mitral prosthesis with normal findings on preopera-
revealed an image suggestive of a thrombus in the
tive angiography. The electrocardiogram obtained
middle segment of the left anterior descending artery
in the emergency department showed negative
straddling the bifurcation with a septal branch.
FIGURE 1
Coronary Embolism of
Thrombotic Material Adhered to a Prosthetic Mitral Valve: Angiography, IVUS, TEE, and Histopathological Findings
(A) Angiography showing thrombus straddling the middle left anterior descending artery and septal branch (arrow). The mitral prosthesis and the tricuspid ring are also seen in the image. (B) Detail of the thrombotic material extracted with the thromboaspiration device. The shape of the thrombus fits the bifurcation zone where it was impacted. (C) Angiography of the artery after thrombectomy, and intravascular ultrasound (IVUS) sections of the bifurcation with septal branch (C2) and proximal (C1) and distal (C3) segments of the bifurcation, showing a normal anatomy of the artery wall without evidence of atherosclerotic plaque neither dissection. (D) Transesophageal echocardiography (TEE) of the mitral prosthesis showing echodense masses adhered (arrows), compatible with thrombus vegetation (E, F). Histopathological analysis of the thrombus extracted (E, Gram stain; F, hematoxylin and eosin) was compatible with a fibrin thrombus.
From the Department of Cardiology, University Hospital Virgen de Arrixaca, Murcia, Spain. The authors have reported that they have no relationships relevant to the contents of this paper to disclose. Manuscript received January 28, 2014; accepted February 13, 2014.
e128
Lacunza-Ruiz et al.
JACC: CARDIOVASCULAR INTERVENTIONS VOL. 7, NO. 10, 2014
Coronary Embolism
OCTOBER 2014:e127–8
Aspiration of thrombotic material was performed, and
must always keep in mind this clinical suspicion in
intracoronary ultrasound showed no damage to the
patients with a cardiac prosthesis or atrial fibrilla-
vessel wall. The international normalized ratio at
tion, especially in cases of subtherapeutic anti-
admission was 1.7, and echocardiography showed an
coagulation. In this particular case, intravascular
echodense mass attached to the mitral prosthesis.
ultrasound and transesophageal echocardiography
Finally,
were essential for the correct diagnosis and subse-
the
histopathological
analysis
of
the
extracted material was compatible with a fibrin
quent treatment.
thrombus (Figure 1). The most frequent cause of acute coronary syn-
REPRINT REQUESTS AND CORRESPONDENCE: Dr.
drome is the thrombotic complication of a coronary
Francisco Javier Lacunza-Ruiz, Cardiology Depart-
plaque. However, we cannot dismiss other possibil-
ment, University Hospital Virgen de la Arrixaca. Ctra.
ities such as a coronary embolism (1,2) when de-
Madrid-Cartagena s/n El Palmar 30120, Murcia, Spain.
termining the diagnostic strategy and treatment. We
E-mail: [email protected].
REFERENCES 1. Lacunza-Ruiz J, Gimeno-Blanes JR, PinarBermúdez E, Valdés-Chávarri M. Coronary embo-
2. Kushiyama S, Ikura Y, Iwai Y. Acute myocardial infarction caused by coronary tumour embolism.
lism after percutaneous implantation of an aortic valve prosthesis. Rev Esp Cardiol 2009;62:1074–5.
Eur Heart J 2013;34:3690.
KEY WORDS acute coronary syndrome, coronary embolism, intravascular ultrasound, prosthetic mitral valve, thrombectomy
VOL. 7, NO. 10, 2014
ª 2014 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION PUBLISHED BY ELSEVIER INC.
ISSN 1936-8798/$36.00 http://dx.doi.org/10.1016/j.jcin.2014.02.025
IMAGES IN INTERVENTION
Coronary Embolism and Thrombosis of Prosthetic Mitral Valve Francisco Javier Lacunza-Ruiz, MD, Carmen Muñoz-Esparza, MD, Juan García-de-Lara, MD
A
66-year-old woman was admitted to our hos-
T waves in leads V2 to V4 , not present on previous
pital with chest pain. Three months earlier,
electrocardiograms. The patient was taken emer-
she underwent implantation of a mechanical
gently to the catheterization laboratory. Angiography
mitral prosthesis with normal findings on preopera-
revealed an image suggestive of a thrombus in the
tive angiography. The electrocardiogram obtained
middle segment of the left anterior descending artery
in the emergency department showed negative
straddling the bifurcation with a septal branch.
FIGURE 1
Coronary Embolism of
Thrombotic Material Adhered to a Prosthetic Mitral Valve: Angiography, IVUS, TEE, and Histopathological Findings
(A) Angiography showing thrombus straddling the middle left anterior descending artery and septal branch (arrow). The mitral prosthesis and the tricuspid ring are also seen in the image. (B) Detail of the thrombotic material extracted with the thromboaspiration device. The shape of the thrombus fits the bifurcation zone where it was impacted. (C) Angiography of the artery after thrombectomy, and intravascular ultrasound (IVUS) sections of the bifurcation with septal branch (C2) and proximal (C1) and distal (C3) segments of the bifurcation, showing a normal anatomy of the artery wall without evidence of atherosclerotic plaque neither dissection. (D) Transesophageal echocardiography (TEE) of the mitral prosthesis showing echodense masses adhered (arrows), compatible with thrombus vegetation (E, F). Histopathological analysis of the thrombus extracted (E, Gram stain; F, hematoxylin and eosin) was compatible with a fibrin thrombus.
From the Department of Cardiology, University Hospital Virgen de Arrixaca, Murcia, Spain. The authors have reported that they have no relationships relevant to the contents of this paper to disclose. Manuscript received January 28, 2014; accepted February 13, 2014.
e128
Lacunza-Ruiz et al.
JACC: CARDIOVASCULAR INTERVENTIONS VOL. 7, NO. 10, 2014
Coronary Embolism
OCTOBER 2014:e127–8
Aspiration of thrombotic material was performed, and
must always keep in mind this clinical suspicion in
intracoronary ultrasound showed no damage to the
patients with a cardiac prosthesis or atrial fibrilla-
vessel wall. The international normalized ratio at
tion, especially in cases of subtherapeutic anti-
admission was 1.7, and echocardiography showed an
coagulation. In this particular case, intravascular
echodense mass attached to the mitral prosthesis.
ultrasound and transesophageal echocardiography
Finally,
were essential for the correct diagnosis and subse-
the
histopathological
analysis
of
the
extracted material was compatible with a fibrin
quent treatment.
thrombus (Figure 1). The most frequent cause of acute coronary syn-
REPRINT REQUESTS AND CORRESPONDENCE: Dr.
drome is the thrombotic complication of a coronary
Francisco Javier Lacunza-Ruiz, Cardiology Depart-
plaque. However, we cannot dismiss other possibil-
ment, University Hospital Virgen de la Arrixaca. Ctra.
ities such as a coronary embolism (1,2) when de-
Madrid-Cartagena s/n El Palmar 30120, Murcia, Spain.
termining the diagnostic strategy and treatment. We
E-mail: [email protected].
REFERENCES 1. Lacunza-Ruiz J, Gimeno-Blanes JR, PinarBermúdez E, Valdés-Chávarri M. Coronary embo-
2. Kushiyama S, Ikura Y, Iwai Y. Acute myocardial infarction caused by coronary tumour embolism.
lism after percutaneous implantation of an aortic valve prosthesis. Rev Esp Cardiol 2009;62:1074–5.
Eur Heart J 2013;34:3690.
KEY WORDS acute coronary syndrome, coronary embolism, intravascular ultrasound, prosthetic mitral valve, thrombectomy
