Unusual causes of STEMI. ESC-SHA Nov 2015 Dr Ali M Alshehri, MD

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1 Unusual causes of STEMI ESC-SHA Nov 2015 Dr Ali M Alshehri, MD Saudi Aramco: Public

2 Clinical Case 1 56 year old man Severe chest pain starting at 3pm Direct admission to catheter lab at 6pm Saudi Aramco: Public

3 EKG Saudi Aramco: Public

4 Saudi Aramco: Public More Targeted History ESR 75 CRP 70 Unwell for 1 year Night sweats Weight loss 2 KG Chest pains for 2 months Previous major surgery for aortic dissection On Warfarin for AVR INR 3.6

5 Angiography Saudi Aramco: Public

6 Angiography Saudi Aramco: Public

7 PCI Export catheter Clot aspirated and flow restored No obvious focal stenosis Decision not to stent Saudi Aramco: Public

8 Saudi Aramco: Public PCI Initial Final

9 Saudi Aramco: Public PCI Debris from Export Catheter unusual grey colour Debris collected and sent for microbiology

10 Echo post PCI Saudi Aramco: Public

11 Post PCI? Diagnosisembolic MI from endocarditis? Aortic root abscess Blood cultures TEE CT of aortic root Saudi Aramco: Public

12 Clinical course Later that night severe vomiting Severe abdominal pain 10/10 Small amounts fresh blood Tender epigastrium Saudi Aramco: Public

13 3 sets blood cultures Started on Gentamycin and Vancomycin Eventually settled Hg 9.4 WCC 14.2 Neut 10.7 Na 135 K 3.5 Cr 126 Saudi Aramco: Public

14 Day 1 Saudi Aramco: Public

15 Saudi Aramco: Public Abrupt cut off splenic artery Hypoperfused large segment of Spleen splenic infarction CT Abdomen

16 Saudi Aramco: Public Day 1 Acute anteroseptal MI Acute splenic infarction Probable mesenteric embolism debris extracted from LAD with Export Cath : Numerous gram +ve cocci CT suspicious aortic root abscess

17 TEE Saudi Aramco: Public

18 Possible Vegetation on AVR Saudi Aramco: Public

19 Diagnosis Acute Embolic Myocardial Infarction Endocarditis Emboli to LAD, Spleen and GIT Aortic Root Abscess Previous Aortic root replacement with mechanical AVR Saudi Aramco: Public

20 Saudi Aramco: Public Microbiology of Aspirated Thrombus Organism identified as alpha haemolytic streptococcus strep mitis Blood cultures negative

21 Clinical case 2 71 year old lady admitted with severe crushing chest pain and collapse Cyanosed Severe pain and distress Unable to give much history Tachycardia 105/min BP 104/80 mmhg O2 sats 89% Bibasal crepitations On-going chest discomfort Saudi Aramco: Public

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23 Emergency Cardiac Catheterization Saudi Aramco: Public

24 LV Angiography Saudi Aramco: Public

25 Echocardiography Saudi Aramco: Public

26 Repeat Echo 4 Weeks Saudi Aramco: Public

27 Saudi Aramco: Public Tako tsubo Cardiomyopathy 1990 :first described in Japanese language by physicians at Hiroshima Asa Hospital 2003: first series published about the condition in Caucasians 2006: Labelled as an acquired cardiomyopathy by AHA Apical Ballooning Syndrome Broken Heart Syndrome Stress Induced Cardomyopathy

28 Saudi Aramco: Public Tako tsubo Cardiomyopathy Transient, reversible systolic dysfunction of left ventricle Exact prevalence unknown as many cases may be undiagnosed? 2% of patients presenting with ACS Up to 7.5% of women presenting with ACS

29 Clinical Case 3 Elderly lady long history of chronic rheumatic heart disease MVR 32 years ago Redo MVR 23 years ago Permanent AF Warfarin INR 1.6 Epigastric painchest Dyspnoea Troponin 7 Admitted to CCU Saudi Aramco: Public

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38 Saudi Aramco: Public Acute Embolic Infarction Partial Thrombosis of MVR + LAA Thrombus due to under anticoagulation

39 Repeat TEE IV Heparin Aspirin Warfarin Saudi Aramco: Public

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42 Thromboembolic Events with Mechanical Valves Annual risk of thromboembolic event is 1 2% 0.7% with bioprosthetic valve Time in therapeutic INR range 60 70% Aspirin 100mg daily in addition to VKA reduces incidence of: Major embolism or death ( %) Stroke 1.3 versus 4.2% Overall mortality 2.8 versus 7.4% Aspirin in addition to Warfarin is Class 1 ACC/AHA 2014 Guideline Level of evidence A Saudi Aramco: Public

43 Saudi Aramco: Public HOW COMMON IS EMBOLIC MI? Probably commoner than we think

44 Acute Myocardial Infarction Caused by Coronary Embolism from Infective Endocarditis. Czarina J Roxas, Anthony J Weekes The Journal of emergency medicine 2008 Oct 21 The Journal of heart valve disease Thrombolytics in infectious endocarditis associated myocardial infarction. A J Hunter, D E Girard The Journal of emergency medicine 2001 Nov A rare complication of infective endocarditis : left main coronary artery embolization resulting in sudden death. Zeller L - J. Heart Valve Dis. - Mar 2010; 19(2): Acute myocardial infarction associated with nonbacterial thrombotic endocarditis. Jaya D Bathina, Iyad N Daher, Juan Carlos Plana, Jean-Bernard Durand, Syed Wamique Yusuf Texas Heart Institute journal / from the Texas Heart Institute of St. Luke's Episcopal Hospital, Texas Children's Hospital 2010 Acute myocardial infarction with left ventricular free wall rupture and papillary muscle rupture caused by infectious endocarditis H Amano, H Kanazaw a, S Nakazaw a, S Shiraishi, K Aoki, Y Takahashi Kyobu geka. The Japanese journal of thoracic surgery 2006 Mar Saudi Aramco: Public

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46 Saudi Aramco: Public Reported causes of Coronary Embolism

47 Saudi Aramco: Public AF and Acute MI Post Mortem Study of 419 patients with MI : coronary embolism occurred in 55 patients. 25% of these were known to have AF

48 Thank you Saudi Aramco: Public