PP-212 ANTERIOR ACUTE MYOCARDIAL INFARCTION DUE TO CORONARY EMBOLISM IN A PATIENT WITH MECHANICAL AORTIC VALVE PROSTHESIS

Introduction: Myocardial infarction secondary to coronary artery embolism in the presence of mechanical aortic valve prosthesis is a rare condition. In this report we aimed to present a case of anterior acute myocardial infarction due to coronary embolism in a 46 year-old-man with mechanical aortic valve prosthesis. Case: A 46-year-old man presented with chest pain for 5 hours. He had undergone aortic valve replacement with St Jude mechanical valve 2 years before. The patient had been using warfarin since the operation. However, it was learnt that he suspended the use of warfarin for 15 days due to emotional stress. Systolic ejection murmur grade 3/6 on the second right parasternal space and a mechanical valve click were the cardiac auscultation findings of the patient. Electrocardiogram showed sinus rhythm and ST elevation in leads DI, aVL, V2-V5 and ST depression in DII, DIII and aVF. Transthorasic echocardiography showed akinesia of anterior and apical segments and ejection fraction was 35%. Maximum 80mmHg, mean 42mmHg gradient was measured on mechanical aortic bileaflet prosthesis. Moderate degree of aortic regurgitation was detected. Dysfunction due to trombus load was considered in aortic valve. The cardiac enzyme levels revealed troponin T level of 2.1 ng/ml and creatinine kinase-MB level of 138U/L. The patient’s INR level was 1.1 and reflecting prothrombotic state. Emergent coronary angiography showed a total occlusion of mid left anterior descending artery. After advancing a 0.014 inch floppy guidewire and passing through the lesion, we tried to aspirate the thrombus by using a thrombus aspiration catheter (Export Medtronic, Minneapolis, Minnesota). After aspiration, thrombus causing partial obstruction in distal was observed. The procedure was ceased. The patient was started intravenous tirofiban. Tirofiban was administered for 30 minutes 0.4m/kg/min intravenous and 0.10mg/kg/min 48 hours infusion. In transesofageal echocardiography in the follow-up valve maximum 30mmHg, mean 14mmHg gradient was taken on the valve. Aortic regurgitation was minimal and no thrombus was found on the valve. The patient was discarded from the hospital with optimal INR value (INR: 3.2). Conclusion: In conclusion, inpatients with prosthesis coronary valve, it should be considered that myocardial infraction due to coronary embolism can develop. The use of glycoprotein IIb/IIIa inhibitors together with catheter aspiration embolectomy to treat these patients can improve results in patients with suspected accompanying prosthetic valve thrombosis.