Simultaneous Acute ST Elevation Myocardial Infarction And Acute Left Subclavian Artery Thrombosis

Transcription

1 Simultaneous Acute ST Elevation Myocardial Infarction And Acute Left Subclavian Artery Thrombosis Chee Yang CHIN, MBChB, MRCP(UK) C.W.L. Chin, P.T.L. Chiam, R.S. Tan National Heart Centre Singapore 26 th August 2012

2 Disclosures None

3 Clinical History 45 year old male Smoker, Hypertensive 3 hour history of acute chest pain AND Simultaneous coldness and discolouration of left hand

4 Presenting ECG

5 Clinical Examination Brachial blood pressure Right 170/90 mmhg Left 120/55 mm Hg Pulses Absent Left Brachial and Radial pulses All other pulses normal

6 Differential Diagnoses Acute STEMI + upper limb ischaemia: 1. Acute Type A Aortic Dissection 2. Simultaneous Coronary Artery and Left Subclavian Artery Occlusion

7 Initial Investigations Chest Xray Unremarkable Targeted transthoracic echo Impaired LV ejection fraction No dissection flap

8 CT Aortogram

9 Coronary Angiography RAO30 CRA21 LAO43 CAU14

10 Coronary Angioplasty After aspiration thrombectomy After coronary stenting

11 Left Subclavian Artery Angiography Before intervention After aspiration thrombectomy

12 Progress Immediately post-angioplasty Asymptomatic Faint left brachial pulse; IV heparin Day 1 Palpable left radial pulse Echo: LV ejection fraction 35%, no clot Day 5 Negative thrombophilia screen Discharged with dual antiplatelets and oral anticoagulation

13 Progress Immediately post-angioplasty Asymptomatic Faint left brachial pulse; IV heparin Day 1 Palpable left radial pulse Echo: LV ejection fraction 35%, no clot Day 5 Negative thrombophilia screen Discharged with dual antiplatelets and oral anticoagulation

14 Progress Immediately post-angioplasty Asymptomatic Faint left brachial pulse; IV heparin Day 1 Palpable left radial pulse Echo: LV ejection fraction 35%, no clot Day 5 Negative thrombophilia screen Discharged with dual antiplatelets and oral anticoagulation

15 Progress 6 week follow up Asymptomatic Left upper limb duplex ultrasound: Patent left subclavian artery; 2cm long 50% stenosis Anticoagulant / Antiplatelet treatment: 3 months oral anticoagulation 1 month thienopyridine Lifelong aspirin

16 Discussion Diagnosis Management Pathophysiology

17 Discussion Diagnosis Acute upper limb ischaemia + ST elevation MI Stanford Type A aortic dissection Dual vessel occlusion of coronary artery and left subclavian artery never described Management Pathophysiology

18 Discussion Diagnosis Management Antiplatelet /Anticoagulant treatment 1 Aortography : Non-invasive vs invasive Risk of catheterising false lumen 2 Urgent CT aortography available Pathophysiology 1. Cannesson et al. Predictors of in-hospital mortality in the surgical management of acute type A aortic dissections: Impact of anticoagulant therapies. Ann Fr Anesth Reanim. 2004;23: Hart et al. Hazard of Retrograde Aortography in Dissecting Aneurysm. Circulation. 1963;27:1140-2

19 Discussion Diagnosis Management Pathophysiology STEMI with rapid intracardiac clot formation and embolisation 3,4 Simultaneous dual vessel embolism 5 Simultaneous dual vessel plaque rupture 6 3. Tanne et al. Incidence and mortality from early stroke associated with acute myocardial infarction in the prethrombotic and thrombolytic eras. JACC. 1997;30(6): Cerebral Embolism Task Force. Cardiogenic brain embolism. Arch Neuro. 1986;43(1): Box et al. Dual coronary emboli in peripartum cardiomyopathy. Texas Heart Institue Journal. 2004;31(4): Rioufol et al. Multiple atherosclerotic plaque rupture in acute coronary syndrome: A three-vessel intravascular ultrasound study. Circulation. 2002;106:804-8.

20 Conclusion First reported case of simultaneous acute MI and left subclavian artery occlusion in absence of previous CABG Diagnostic and management challenge Embolisation of thrombus to unusual sites must be considered in patients with acute MI and non-coronary ischaemia

21 Thank you National Heart Centre Singapore New Building 2013