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A case of inferior wall with right ventricular myocardial infarction with a thrombus in root of aorta treated by thrombolysis
IHJ Cardiovascular Case Reports (CVCR) 1 (2017) 51–53
Contents lists available at ScienceDirect
IHJ Cardiovascular Case Reports (CVCR) journal homepage: www.elsevier.com/locate/ihjccr
Case Report
A case of inferior wall with right ventricular myocardial infarction with a thrombus in root of aorta treated by thrombolysis Johann Christopher ∗ , K. Vempati Vishwakranth, Praneeth Polamuri, Syed Shahnawaz Ali Care Hospitals, Hyderabad, India
a r t i c l e Keywords: Inferior wall RVMI Aortic thrombus Thrombolysis
i n f o
a b s t r a c t A patient with an acute inferior wall with right ventricular myocardial infarction was presented in Killip class I in a hemodynamically stable condition. He was taken up for primary angioplasty; coronary angiogram revealed a mass in the right coronary sinus extending into the ascending aorta which on a subsequent contrast CT scan was found to be suggestive of a thrombus. He was treated with IV thrombolysis (Tenecteplase) which led to a shower of microemboli into the renal and mesenteric circulation. Patient recovered without any need for further intervention. © 2016 The Author(s). Published by Elsevier B.V. on behalf of Cardiological Society of India. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/ 4.0/).
1. Case report A 50-year-old male non-smoker with no risk factors presented to us with a history of ongoing pain in the interscapular region 10 h prior to admission. Pain was severe, radiating down the back, associated with sweating and shortness of breath (NYHA class III) followed by an episode of syncope. He was presented in a hemodynamically stable condition to the ER of our hospital. Examination revealed a pulse rate of 78 beats per minute with a blood pressure of 100/70 mmHg. His cardiovascular examination revealed an elevated JVP with a prominent RV S3. His ECG showed normal sinus rhythm with ST elevations in lead III, AVF, RV3 and
RV4. He was diagnosed as acute inferior wall with right ventricular myocardial infarction. Transthoracic echocardiography showed grossly dilated RA/RV, RV free wall hypokinesia with moderate RV dysfunction. LV function was normal. In view of ST elevation myocardial infarction patient was taken up for primary PTCA. Coronary angiogram (radial access) revealed a normal left system with a co-dominant circulation. Right coronary artery injection revealed an ostioproximal critical lesion with thrombus with distal vessel TIMI 1 flow. A pedunculated mass (? thrombus) was seen in the right coronary sinus with a mobile element in the ascending aorta (Figure 1a and 1b).
∗ Corresponding author. E-mail address: [email protected] (J. Christopher). http://dx.doi.org/10.1016/j.ihjccr.2016.09.003 2468-600X/© 2016 The Author(s). Published by Elsevier B.V. on behalf of Cardiological Society of India. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/).
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J. Christopher et al. / IHJ Cardiovascular Case Reports (CVCR) 1 (2017) 51–53
In view of a high suspicion of type A aortic dissection, an urgent coronary CT angiography with aortogram was done to delineate the coronary arteries, the mass and the aortic root. It revealed a large pedunculated hypodense filling defect in the right coronary cusp attached to the RCA ostium, extending into the ascending aorta lumen suggestive of thrombus (Figure 2a and 2b). Left anterior descending artery and obtuse marginal arteries showed evidence of atherosclerotic changes with mild narrowing. RCA showed an
ostioproximal critical stenosis with superimposed thrombus. RA and RV was dilated with RV dysfunction. There was no evidence of thrombi in the left atrial appendage, both atria and the ventricles. An urgent surgical opinion was taken for excision of the aortic mass, which was supported by an extensive literature search. However the surgeon was reluctant to operate in view of the significant RV dysfunction and the family refused to give high-risk consent for the procedure. In view of the mass being highly suggestive of a thrombus based on our experience and CT characteristics it was decided to thrombolyse the patient with IV Tenecteplase followed by heparin infusion, antiplatelets and statins. His chest pain was relieved and he was hemodynamically stable 1 h after the infusion. Six hours post thrombolysis the patient complained of severe abdominal pain, his pulse rate was 140 beats per minute, blood pressure was 130/80 mmHg, and the abdomen was soft with tenderness localised to the left hypochondriac region.
A clinical diagnosis of mesenteric ischaemia was considered and he underwent an IV contrast enhanced CT abdomen with coverage of the entire aorta. The scan revealed bilateral small renal infarcts, oedematous mildly enhancing changes in the ascending colon, short segment of transverse colon, descending colon and junction of descending colon and sigmoid colon, bilateral mild pleural effusion with underlying lung collapse (Figure 2c). The mesenteric and renal vessels were free of thrombus. The right coronary sinus was found to be free of the pedunculated thrombus (Figure 2d).
Patient was taken up for laparoscopy under general anaesthesia to evaluate the bowel ischaemia, which subsequently revealed no evidence of mesenteric ischaemia and very minimal free fluid in the pelvis. Patient was stabilised with analgesics and intravenous fluids. He made a gradual uneventful recovery. The current plan is to keep him on conservative medical management and perform a check angiogram prior to discharge. He has been planned for evaluation of coagulation disorders on follow-up.
2. Discussion In the present case the pathophysiology of inferior and right ventricular myocardial infarction is an isolated thrombus in the aortic root, the aetiology of which is unknown. Contrast enhanced CT did not reveal any thrombus in any of the cardiac chambers neither was there any evidence of a patent foramen ovale. There
J. Christopher et al. / IHJ Cardiovascular Case Reports (CVCR) 1 (2017) 51–53
was also no evidence of erosive lesions, atheromatous plaques or localised dissection in the aortic root. CT scan showed atheromatous plaques in LAD, LCX and a critical stenosis in ostioproximal RCA. The possibility of thrombus forming in RCA and extending to aortic root cannot be ruled out and looks to be the likely cause. Management strategies of such patients from limited series involve surgical extraction of the thrombus.1,2 Thrombolytic therapy can be tried with a risk of peripheral thromboembolic episodes and stroke. In our case as the thrombus burden was large with a mobile element and an ongoing STEMI, a decision of thrombolysis was taken after detailed discussion with the family members regarding the inherent risk of embolic phenomena. Thrombolytic therapy using IV Tenecteplase at a dose of 40 mg successfully dissolved the thrombus in the aortic root with mild mesenteric and renal ischaemia, which was successfully managed by conservative therapy. 3. Conclusion Thrombus in aortic root in an uncommon and life threatening condition3 with possible catastrophic complications.
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Multimodality imaging needs to be used for early diagnosis. Therapeutic options needs to be carefully selected. Surgical excision of the mass is the first option and is supported by case reports in literature. However, if the patients surgical risk is extremely high thrombolytic therapy can be attempted after discussion with the family about complications and benefits of the option. Conflicts of interest The authors have none to declare. References 1. Scott DJ, White JM, Arthurs ZM. Endovascular management of a mobile thoracic aortic thrombus following recurrent distal thromboembolism: a case report and literature review. Vasc Endovascular Surg. 2014;48(April (3)):246–250, http://dx.doi.org/10.1177/1538574413513845. 2. Szabolcs Z, Veres G, Hüttl T, et al. A simple surgical method for removing a large floating thrombus from the ascending aorta. Orv Hetil. 2007;148(February (8)):363–366 [in Hungarian]. 3. Bruno P, Massetti M, Babatasi G, et al. Catastrophic consequences of a free floating thrombus in ascending aorta. Eur J Cardiothorac Surg. 2001;19(January (1)):99–101.
Contents lists available at ScienceDirect
IHJ Cardiovascular Case Reports (CVCR) journal homepage: www.elsevier.com/locate/ihjccr
Case Report
A case of inferior wall with right ventricular myocardial infarction with a thrombus in root of aorta treated by thrombolysis Johann Christopher ∗ , K. Vempati Vishwakranth, Praneeth Polamuri, Syed Shahnawaz Ali Care Hospitals, Hyderabad, India
a r t i c l e Keywords: Inferior wall RVMI Aortic thrombus Thrombolysis
i n f o
a b s t r a c t A patient with an acute inferior wall with right ventricular myocardial infarction was presented in Killip class I in a hemodynamically stable condition. He was taken up for primary angioplasty; coronary angiogram revealed a mass in the right coronary sinus extending into the ascending aorta which on a subsequent contrast CT scan was found to be suggestive of a thrombus. He was treated with IV thrombolysis (Tenecteplase) which led to a shower of microemboli into the renal and mesenteric circulation. Patient recovered without any need for further intervention. © 2016 The Author(s). Published by Elsevier B.V. on behalf of Cardiological Society of India. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/ 4.0/).
1. Case report A 50-year-old male non-smoker with no risk factors presented to us with a history of ongoing pain in the interscapular region 10 h prior to admission. Pain was severe, radiating down the back, associated with sweating and shortness of breath (NYHA class III) followed by an episode of syncope. He was presented in a hemodynamically stable condition to the ER of our hospital. Examination revealed a pulse rate of 78 beats per minute with a blood pressure of 100/70 mmHg. His cardiovascular examination revealed an elevated JVP with a prominent RV S3. His ECG showed normal sinus rhythm with ST elevations in lead III, AVF, RV3 and
RV4. He was diagnosed as acute inferior wall with right ventricular myocardial infarction. Transthoracic echocardiography showed grossly dilated RA/RV, RV free wall hypokinesia with moderate RV dysfunction. LV function was normal. In view of ST elevation myocardial infarction patient was taken up for primary PTCA. Coronary angiogram (radial access) revealed a normal left system with a co-dominant circulation. Right coronary artery injection revealed an ostioproximal critical lesion with thrombus with distal vessel TIMI 1 flow. A pedunculated mass (? thrombus) was seen in the right coronary sinus with a mobile element in the ascending aorta (Figure 1a and 1b).
∗ Corresponding author. E-mail address: [email protected] (J. Christopher). http://dx.doi.org/10.1016/j.ihjccr.2016.09.003 2468-600X/© 2016 The Author(s). Published by Elsevier B.V. on behalf of Cardiological Society of India. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/).
52
J. Christopher et al. / IHJ Cardiovascular Case Reports (CVCR) 1 (2017) 51–53
In view of a high suspicion of type A aortic dissection, an urgent coronary CT angiography with aortogram was done to delineate the coronary arteries, the mass and the aortic root. It revealed a large pedunculated hypodense filling defect in the right coronary cusp attached to the RCA ostium, extending into the ascending aorta lumen suggestive of thrombus (Figure 2a and 2b). Left anterior descending artery and obtuse marginal arteries showed evidence of atherosclerotic changes with mild narrowing. RCA showed an
ostioproximal critical stenosis with superimposed thrombus. RA and RV was dilated with RV dysfunction. There was no evidence of thrombi in the left atrial appendage, both atria and the ventricles. An urgent surgical opinion was taken for excision of the aortic mass, which was supported by an extensive literature search. However the surgeon was reluctant to operate in view of the significant RV dysfunction and the family refused to give high-risk consent for the procedure. In view of the mass being highly suggestive of a thrombus based on our experience and CT characteristics it was decided to thrombolyse the patient with IV Tenecteplase followed by heparin infusion, antiplatelets and statins. His chest pain was relieved and he was hemodynamically stable 1 h after the infusion. Six hours post thrombolysis the patient complained of severe abdominal pain, his pulse rate was 140 beats per minute, blood pressure was 130/80 mmHg, and the abdomen was soft with tenderness localised to the left hypochondriac region.
A clinical diagnosis of mesenteric ischaemia was considered and he underwent an IV contrast enhanced CT abdomen with coverage of the entire aorta. The scan revealed bilateral small renal infarcts, oedematous mildly enhancing changes in the ascending colon, short segment of transverse colon, descending colon and junction of descending colon and sigmoid colon, bilateral mild pleural effusion with underlying lung collapse (Figure 2c). The mesenteric and renal vessels were free of thrombus. The right coronary sinus was found to be free of the pedunculated thrombus (Figure 2d).
Patient was taken up for laparoscopy under general anaesthesia to evaluate the bowel ischaemia, which subsequently revealed no evidence of mesenteric ischaemia and very minimal free fluid in the pelvis. Patient was stabilised with analgesics and intravenous fluids. He made a gradual uneventful recovery. The current plan is to keep him on conservative medical management and perform a check angiogram prior to discharge. He has been planned for evaluation of coagulation disorders on follow-up.
2. Discussion In the present case the pathophysiology of inferior and right ventricular myocardial infarction is an isolated thrombus in the aortic root, the aetiology of which is unknown. Contrast enhanced CT did not reveal any thrombus in any of the cardiac chambers neither was there any evidence of a patent foramen ovale. There
J. Christopher et al. / IHJ Cardiovascular Case Reports (CVCR) 1 (2017) 51–53
was also no evidence of erosive lesions, atheromatous plaques or localised dissection in the aortic root. CT scan showed atheromatous plaques in LAD, LCX and a critical stenosis in ostioproximal RCA. The possibility of thrombus forming in RCA and extending to aortic root cannot be ruled out and looks to be the likely cause. Management strategies of such patients from limited series involve surgical extraction of the thrombus.1,2 Thrombolytic therapy can be tried with a risk of peripheral thromboembolic episodes and stroke. In our case as the thrombus burden was large with a mobile element and an ongoing STEMI, a decision of thrombolysis was taken after detailed discussion with the family members regarding the inherent risk of embolic phenomena. Thrombolytic therapy using IV Tenecteplase at a dose of 40 mg successfully dissolved the thrombus in the aortic root with mild mesenteric and renal ischaemia, which was successfully managed by conservative therapy. 3. Conclusion Thrombus in aortic root in an uncommon and life threatening condition3 with possible catastrophic complications.
53
Multimodality imaging needs to be used for early diagnosis. Therapeutic options needs to be carefully selected. Surgical excision of the mass is the first option and is supported by case reports in literature. However, if the patients surgical risk is extremely high thrombolytic therapy can be attempted after discussion with the family about complications and benefits of the option. Conflicts of interest The authors have none to declare. References 1. Scott DJ, White JM, Arthurs ZM. Endovascular management of a mobile thoracic aortic thrombus following recurrent distal thromboembolism: a case report and literature review. Vasc Endovascular Surg. 2014;48(April (3)):246–250, http://dx.doi.org/10.1177/1538574413513845. 2. Szabolcs Z, Veres G, Hüttl T, et al. A simple surgical method for removing a large floating thrombus from the ascending aorta. Orv Hetil. 2007;148(February (8)):363–366 [in Hungarian]. 3. Bruno P, Massetti M, Babatasi G, et al. Catastrophic consequences of a free floating thrombus in ascending aorta. Eur J Cardiothorac Surg. 2001;19(January (1)):99–101.