Concomitant Left Ventricular Aneurysm and Ventricular Septal Defect Following Acute Inferior Myocardial Infarction from In-Stent Thrombosis in a Post CABG Patient-Juniper Publishers
JUNIPER PUBLISHERS-OPEN ACCESS JOURNAL OF CARDIOLOGY & CARDIOVASCULAR THERAPY
Abstract
Mechanical complications of acute myocardial
infarction are rare. Additionally, concomitant complications in the same
patient are even even less common, particularly in the revascularized
patient. Here, we present a case of concomitant left ventricular
inferior/inferoseptal aneurysm and ventricular septal defect as parallel
complications of an acute inferior ST elevation myocardial infarction
from in-stent thrombosis of a drug-eluting stent to the SVG-RCA graft in
a patient after coronary artery bypass graft surgery. Our case is also
unique in that we employed multiple cardiac imaging modalities,
particularly cardiac magnetic resonance imaging, to delineate the
anatomic complexity of the two concomitant complications, which was
essential in defining the appropriate course of surgical management.
Keywords: Myocardial Infarction;
Ventricular Septal Rupture; Left Ventricular Aneurysm;
Echocardiography; Cardiac Magnetic Resonance Imaging
Abbreviations: CAD: Coronary
Artery Disease; PCI: Percutaneous Coronary Intervention; DES:
Drug-Eluting Stent; PAP: Pulmonary Artery Pressure; 2D TTE:
Two-dimensional Transthoracic Echocardiogram, CABG: coronary artery
bypass graft, STEMI: ST segment elevation myocardial infarction
Case Report
A 73 year-old male with a history of hypertension, coronary
artery disease (CAD), triple vessel CABG (LIMA-LAD, SVG-ramus,
SVG-RCA in 2008) (Video Clip 1), and an unrepaired abdominal
aortic aneurysm was transferred for management of acute
decompensated heart failure. He had multiple admissions to the
outside hospital. His first hospitalization was August 2015. At
that time, he presented with chest pain and was found to have
an acute inferior STEMI for which he underwent percutaneous
coronary intervention (PCI) with placement of a single drugeluting
stent (DES) to his SVG-RCA graft. He was discharged on
aspirin and clopidogrel. However, he returned 6 days later with recurrent chest pain. He was found to have a new inferior STEMI.
Coronary angiogram revealed complete occlusion of the recently
placed DES due to in-stent thrombosis. He underwent aspiration
thrombectomy and PCI with placement of 3 DESs in the SVG-RCA
graft.
Case Presentation
Case Presentation
It was believed our patient failed on clopidogrel.
Consequently, he was discharged on ticagrelor only to return 12
days after his initial hospitalization. He reported chest pain and
shortness of breath. His ECG revealed fragmented QRS complexes
in leads III and aVF consistent with his prior inferior myocardial
infarction. He was diagnosed with acute decompensated heart
failure and placed on dobutamine and furosemide drips. Despite
diuresis, his symptoms persisted. The echocardiogram revealed
LVEF 60-65%, hypokinesis of the septal and inferior walls, a
possible VSD, RV systolic dysfunction, and severe pulmonary
hypertension. Given these findings and his persistent dyspnea, he
was transferred to our coronary care unit for further evaluation
and management.
At the time of transfer he was on dobutamine 3mcg/kg/min.
His vitals were stable. Physical exam was notable for bibasilar
crackles, jugular venous distention, harsh V/VI holosystolic
murmur at the LLSB with widespread radiation, a palpable thrill,
and 2+ lower extremity edema to the knees bilaterally. Labs were
notable for brain natriuretic peptide of 903 pg/ml and troponin I
levels of 0.11 ng/ml, 0.06 ng/ml, and 0.05 ng/ml. His ECG showed
normal sinus rhythm and fragmented QRS complexes in III, aVF.
Chest X-ray displayed bilateral and diffuse opacities consistent
with pulmonary edema. Right heart catheterization data was as
follows: right atrial pressure 8 mmHg, right ventricular pressure
67/3 mmHg, pulmonary artery pressure (PAP) 62/21 mmHg,
mean PAP 38mmHg, and pulmonary capillary wedge pressure
21mmHg (with V waves to 40mmHg). A shunt study revealed a
21% step up in going from the RA to the RV suggestive of a VSD
with left to right shunting. The Qp: Qs was 2.2. Graft angiography
illustrated patent LIMA-LAD and SVG-Ramus grafts. The SVGRCA
graft was visualized with numerous stents and displayed
poor overall flow (TIMI 2 flow); yet there was no evidence of
complete obstruction (Video Clip 1).
At surgery, there was a true aneurysm of the inferior LV;
this defect was large and extended from the base to the apex
measuring approximately 4.5cm in depth and 1.7cm in width at
the neck. The aneurysm extended into the RV toward the apex
and measured approximately 2.5cm. Both defects were patch
repaired using a bovine pericardial patch completely excluding
the LV aneurysm and closing the VSD. The post repair TEE
revealed complete exclusion of the LV aneurysm from the LV cavity without evidence of flow into the aneurysm. Likewise, the
VSD was closed and there was no evidence of left to right shunt
with Qp: Qs of 1.0. Post-operatively, the patient did fairly well
and was ultimately discharged to home 2 weeks after arriving at
our institution.
In the era of coronary revascularization, the prevalence and
incidence of post MI complications is low [1,2]. Additionally, the
co-existence of multiple complications is even less common,
particularly in the re-vascularized patient [3,4]. There have
been prior reports of concomitant LVA and VSD. For example,
Heath and colleagues described a case of concomitant inferior
LV aneurysm and apical VSD discerned at surgery in a patient
following an inferior ST elevation MI [5]. Rogers et al. [6]
identified concomitant posterior VSD with a discrete aneurysm
of the posterior interventricular septum in 6 consecutive
patients with acute inferior myocardial infarctions. Also,
numerous studies have described anterior, anteroapical, or
apical aneurysms and associated VSDs identified by 2D TTE in
patients suffering an acute left anterior descending ST elevation
MI [7-9].
Conclusion
Conclusion
There are several novel aspects of our case. First, nearly all
of the case reports in the literature detail anterior, anteroapical,
or apical LVAs while we describe a case of an inferior/
inferoseptal LVA. Second, we describe concomitant LVA and
VSD in a revascularized patient, which has not been illustrated
previously. Third, the mechanism of post MI complications in our
case is unique in that in-stent thrombosis of the DES to his SVGRCA
graft proved to be the ultimate cause of the concomitant LVA
and VSD. Fourth, in terms of imaging the complications, 2D TTE
by and large was the imaging modality of choice. However in our
case 2D TTE, while it did reveal the inferior/inferoseptal LVA, did
not illustrate the complex interplay between the LVA and VSD.
Cardiac MRI was essential in order to detail the complex anatomy
of the LVA and associated VSD and consequently aid in surgical
decision making. In the era of coronary revascularization, we
believe our case is the first of its kind.
For more articles in Open Access Journal of
Cardiology & Cardiovascular Therapy please click on:
https://juniperpublishers.com/jocct/index.php
https://juniperpublishers.com/jocct/index.php
Comments
Post a Comment