A „usualˮ STEMI? A team based approach of a systemic cardioembolism case

Introduction: Cardiac embolism is a relatively rare cause of STEMI, which is oft en associated with other multiple site embolisms. The 52 year old patient is transferred to our hospital for posterior STEMI and acute right lower limb ischemia (simultaneous onset nine hours before). He was an active smoker, diabetic, hypertensive, without any medication, with a recent surgical procedure (seven days ago) for an ischiorectal abscess. In the Emergency Room: BP=120/75 mm Hg, HR=100 bpm, irregular, without signs of systemic congestion, persistent angina pectoris at rest, with signs and symptoms of acute right lower limb ischemia, ECG: AF, RBBB, 3 mm ST-T segment elevation in V6- V9 leads. Echocardiography: anterior and lateral wall hypokinesia, LVEF 45%, no signifi cant valvular disease. Methods: Emergency coronary angiography by left femoral approach revealed a large thrombus in the distal left main, extending in the proximal segments of the LAD and LCX arteries; an eccentric 50% lesion in the mid-LAD, and normal RCA. Thrombus aspiration with 7F Export catheter was performed in the LM, removing a large quantity of thrombus, but distal embolization in the mid LAD and distal LCX is noted. After two bolus doses of eptifi batide, followed by another thrombus aspiration, the LCX’s fl ow becomes TIMI3, but the mid-LAD remained totally occluded. Multiple balloon inflations were performed at this site, followed by stenting of the dissection in this segment. After stent implantation distal TIMI 3 fl ow and myocardial blush grade 3 were regained in the LAD territory. Results: Right inferior limb angiography revealed total occlusion of the common right femoral (CFA) artery, proximal to its bifurcation. Thrombus aspiration and balloon angioplasty were performed in the right CFA, SFA and PFA, regaining distal fl ow, but with residual thrombus lodged in the SFA-PFA bifurcation. I.v. eptifibatide and unfractioned heparin were continued for 24 hours. After the procedure, the patient was free of angina. Control peripheral angiography is performed 10 hours aft er the emergency procedure due to the persistence of acute right lower limb ischemia. It revealed residual thrombus at both SFA-PFA bifurcation. The patient was transferred to the Vascular Surgery for bilateral ilio-femuro-popliteal thrombectomy by Fogarty catheter, with a clear improvement of symptoms Conclusions: In conclusion, we present the case of a patient with recurrent atrial fibrillation, multiple cardiovascular risk factors (hypertension, diabetes, smoking) and systemic embolism (coronary arteries, lower limbs), successfully managed by a team based approach (interventional cardiologist and vascular surgeon).

ISSN – online: 2734 – 6382
ISSN-L 1220-658X
ISSN – print: 1220-658X
The Romanian Journal of Cardiology is indexed by:
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CODE: 379
CME Credits: 10 (Romanian College of Physicians)