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      Acute Myocardial Infarction Due to Coronary Artery Embolism in a 22-Year-Old Woman with Mitral Stenosis with Atrial Fibrillation Under Warfarinization: Successful Management with Anticoagulation

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          Patient: Female, 22

          Final Diagnosis: Acute myocardial infarction due to coronary artery embolism in a 22-year-old woman with mitral stenosis with atrial fibrillation under warfarinization: successful management with anticoagulation

          Symptoms: Chest pain

          Medication: —

          Clinical Procedure: Coronary angiography

          Specialty: Cardiology


          Rare co-existance of disease or pathology


          Coronary artery embolization is an exceedingly rare cause of myocardial infarction, but a few cases in association with prosthetic mechanical valves have been reported. We report a case of embolic myocardial infarction caused by a thrombus in the left atrium with deranged coagulation profile in a patient with critical mitral stenosis under warfarinization.

          Case Report:

          A 22-year-old woman was taken to the catheterization lab for early coronary intervention in lieu of non-ST elevation myocardial infarction. Electrocardiography showed T↓ in V 1 to V 4, and atrial fibrillation with controlled ventricular rate. Coronary angiography showed total occlusion of the mid-left anterior descending artery with thrombus. After upstream treatment with tirofiban, the apparent thrombus was dislodged distally while passing a BMW wire. No abnormalities were seen by intravascular ultrasound study. Echocardiography revealed critical mitral stenosis, and left atrial clot with mild left ventricular dysfunction. Coagulation profile revealed sub-therapeutic international normalized ratio levels. The sequential angiographic images, normal intravascular ultrasound study, and presence of atrial fibrillation are confirmatory of coronary embolism as the cause of myocardial infarction. Anticoagulation and treatment of acute coronary syndrome were initiated and she was referred for closed mitral valvulotomy.


          Coronary artery thromboembolism as a nonatherosclerotic cause of acute coronary syndrome is rare. The treatment consists of aggressive anticoagulation, antiplatelet therapy, and interventional options, including simple wiring when possible. In this context, primary prevention in the form of patient education on optimal anticoagulation with oral vitamin K antagonist and medical advice about imminent thromboembolic risks are of extreme importance.

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          Most cited references 9

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          Coronary artery embolism and myocardial infarction.

          Although coronary artery embolism is a recognized entity, there is little morphologic information indicating it is a cause of myocardial infarction. We studied patients with coronary artery embolic infarcts, which comprised 13% of our autopsy-studied infarcts. Underlying diseases predisposing to coronary emboli included valvular heart disease (40%), myocardiopathy (29%), coronary atherosclerosis (16%), and chronic atrial fibrillation (24%). Mural thrombi were present in 18 (33%). Myocardial infaction, clinically diagnosed in 15 (27%) patients, caused death in 11 (20%). Most emboli involved the left coronary artery and lodged distally, causing infarcts that were usually transmural. Because of their distal location and recanalization, coronary emboli may be a cause of infarcts with angiographically normal coronaries. Thus, coronary emboli are not rare, may produce signs and symptoms indistinguishable from altherosclerotic coronary disease, and by lodging distally in coronary arteries that are usually previously normal, they most often cause small but transmural myocardial infarction.
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            Coronary saddle embolism causing myocardial infarction in a patient with mechanical mitral valve prosthesis: treatment with thrombolytic therapy.

            Coronary embolism is an uncommon cause for myocardial infarction in clinical practice and there is no consensus on the treatment of this subject. Thrombolytic agents and percutaneous intervention are up to date options and yet there are only a few case reports regarding thrombolytic therapy in this special subgroup of patients suffering from myocardial infarction. We reported a 37-year-old woman patient with non-ST elevation myocardial infarction due to coronary embolism who was successfully treated using intravenous thrombolytic therapy with tissue plasminogen activator.
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              Embolic myocardial infarction in a pregnant woman with a mechanical heart valve on low molecular weight heparin.

              Even with continuing technical improvements in prosthesis design and the development of less thrombogenic materials, mechanical valve prostheses still carry a thromboembolic risk significant enough to warrant long-term anticoagulation therapy. Optimal anticoagulation is especially crucial during pregnancy due to the hypercoagulable state that rapidly develops after conception. Conventional anticoagulation therapy with coumarin derivatives is associated with risks of teratogenicity and hemorrhage for the fetus, and thromboembolic and hemorrhagic complications for the mother. As a result, other forms of anticoagulation, such as unfractionated or low molecular weight heparin, have been advocated as an alternative in selected cases. The present report describes a case of embolic myocardial infarction occurring in a pregnant woman with an aortic bileaflet mechanical valve prosthesis while on therapeutic low molecular weight heparin after only one dose was withheld before amniocentesis.

                Author and article information

                Am J Case Rep
                Am J Case Rep
                The American Journal of Case Reports
                International Scientific Literature, Inc.
                07 April 2017
                : 18
                : 361-366
                Department of Cardiology, LPS Institute of Cardiology, Ganesh Shankar Vidyarthi Memorial (G.S.V.M.) Medical College, Kanpur, India
                Author notes

                Authors’ Contribution:


                Study Design


                Data Collection


                Statistical Analysis


                Data Interpretation


                Manuscript Preparation


                Literature Search


                Funds Collection

                Conflict of interest: None declared

                Corresponding Author: Santosh Kumar Sinha, e-mail: fionasan@
                © Am J Case Rep, 2017

                This work is licensed under Creative Common Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0)



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