Acute Cardiac Care

ISSN: 1748-2941 (Print) 1748-295X (Online) Journal homepage: http://www.tandfonline.com/loi/iacc20

Acute myocardial infarction due to coronary artery

embolus associated with atrial fibrillation

Bo Xu, Paul Williams & Andrew T. Burns

To cite this article: Bo Xu, Paul Williams & Andrew T. Burns (2013) Acute myocardial infarction
due to coronary artery embolus associated with atrial fibrillation, Acute Cardiac Care, 15:4, 93-95,
DOI: 10.3109/17482941.2013.835828

To link to this article: https://doi.org/10.3109/17482941.2013.835828

Published online: 25 Oct 2013.

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 92 B. Xu et al.
overdose with an aim to provide hemodynamic support while
redistributing the toxic agent away from the heart.
Declaration of interest: The authors report no conflicts of
interest. The authors alone are responsible for the content
and writing of the paper.
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Acute myocardial infarction due to coronary artery embolus
associated with atrial fibrillation
DOI: 10.3109/17482941.2013.835828
Bo Xu, Paul Williams & Andrew T. Burns
Department of Cardiology, St Vincent's Hospital Melbourne, Victoria, Australia
Coronary artery embolus is a rare and potentially under-
recognised cause of acute myocardial infarction. We
describe the case of an 80-year-old woman presenting
with an acute coronary syndrome secondary to coronary
artery embolus associated with atrial fibrillation, which
was successfully treated with the use of a thrombectomy
aspiration catheter.
Keywords: Acute myocardial infarction, acute coronary syndrome,
coronary artery embolus, atrial fibrillation, thrombectomy
aspiration
Introduction
Acute coronary syndromes consisting of chest pain,
electrocardiographic changes and cardiac enzyme elevations
have diverse aetiologies. Clinicians treating patients present-
Correspondence: Bo Xu, Department of Cardiology, St Vincent's Hospital Melbourne, Victoria Parade, Fitzroy, Victoria, Australia 3065. Fax: ⫹ 61 3
9288 4422. E-mail: bo.xu@svhm.org.au
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Hemofiltration clearance of flecainide in a patient with acute
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ing with acute coronary syndromes need to be aware that not
all acute coronary syndromes are due to thrombotic occlu-
sion of coronary arteries following acute plaque rupture.
Here, we describe the case of an 80-year-old woman present-
ing with an acute coronary syndrome due to a coronary
artery embolus most likely associated with recent onset par-
oxysmal atrial fibrillation. This was successfully managed
with the use of an aspiration thrombectomy catheter.
Case report
An 80-year-old woman with a history of hypertension,
dyslipidaemia and previously treated localised breast cancer,
presented to a regional hospital with central chest heaviness.
Electrocardiogram demonstrated atrial fibrillation (AF) with
a rapid ventricular response rate and ST-segment depression
in the inferior and antero-lateral leads (Figure 1). High
Acute Cardiac Care
 Myocardial infarction due to coronary artery embolus 93

Figure 1. Electrocardiogram demonstrated atrial fibrillation with a rapid ventricular response rate and ST-segment depression in leads II, III, aVF,
and V1 to V5. Scale: 25 mm/s; 10 mm/mV.
Downloaded by [36.68.116.25] at 18:34 26 December 2017

sensitivity troponin T was elevated at 1391 (normal ⬍ 14 sinus rhythm. Coronary angiography demonstrated a hazy
ng/l). She was treated with anti-platelet agents, beta-blockade, abnormality in the distal left main trunk, extending into the
a statin and anti-coagulation with low molecular weight ostium of the left circumflex artery (Figure 2A, 2B). The
heparin. On transfer to our institution, she had reverted to remainder of the left circumflex artery was disease free. The

Figure 2. Coronary angiogram demonstrated a hazy filling defect (arrow) at the bifurcation of the distal left main trunk and left circumflex
artery, depicted in right anterior oblique caudal (A) and left anterior oblique caudal projections (B). A fibrous mass was aspirated by
a thrombectomy catheter (C), with resolution of the filling defect on coronary angiogram (arrow, D). LAD, left anterior descending artery;
LCx, left circumflex artery.

© 2013 Informa UK, Ltd.

 94 B. Xu et al.
left anterior descending and right coronary arteries were free
of atheromatous disease. Left ventriculogram demonstrated
normal left ventricular systolic function.
Manual aspiration via a 7 French thrombectomy catheter
(Export catheter; Medtronic, MA, USA) successfully retrieved
a pink fibrous mass from the bifurcation of the distal left main
trunk and left circumflex artery (Figure 2C). Coronary angio-
gram post aspiration demonstrated no remaining obstructive
lesions in the left main trunk and left circumflex artery
(Figure 2D). Therefore, no angioplasty or stenting was under-
taken. Given the new diagnosis of paroxysmal AF, and the
appearance of the hazy abnormality in the distal left main
trunk, we had a high suspicion that the culprit may be a
coronary artery embolus related to AF. The appearance of the
retrieved mass was consistent with an embolus. The following
day, the patient had a further episode of asymptomatic AF.
Transthoracic echocardiography showed good left ventricular
function and no evidence of an intra-cardiac mass or shunt.
As part of management for AF, our patient was anticoagu-
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lated with warfarin. She was discharged on day four of admis-
sion, and has remained clinically well.
Discussion
Acute myocardial infarction due to coronary artery embolus
is rare. Sources of coronary artery embolus include vegeta-
tions from infective endocarditis, and intra-cardiac thrombi
(1, 2). Primary angioplasty and stenting, with aggressive
anticoagulation is one management strategy, however,
distal embolisation of the embolus during angioplasty is a
feared complication (3). This can be a risky management
strategy, as illustrated by a previous case report of a
64-year-old man who presented with an acute anterior
myocardial infarction due to coronary artery embolus
associated with atrial fibrillation (3). Despite rescue angio-
plasty after failed thrombolysis achieving satisfactory
angiographic result, the patient died from intracranial hae-
morrhage due to aggressive anticoagulation (3). Thrombus
aspiration has been shown to result in better reperfusion
and clinical outcomes than conventional percutaneous
coronary intervention in patients with ST-segment eleva-
tion myocardial infarction (4). However, the application of
thrombectomy aspiration catheter in coronary artery
embolus due to AF has been reported in only one case
previously (5). A 72-year-old man with an inferior ST-
segment elevation myocardial infarction was treated with
an aspiration catheter, retrieving a large embolus from the
right coronary artery (5). Our case further demonstrates
the effectiveness and safety of thrombectomy catheter
aspiration for acute myocardial infarctions due to coro-
nary artery emboli. Our case also serves to highlight the
importance of considering coronary artery embolus as a
potential cause of acute coronary syndrome, when patients
with otherwise normal coronary arteries are found to have
localised filling defects on coronary angiography.
Declaration of interest: The authors report no conflicts of
interest. The authors alone are responsible for the content
and writing of the paper.
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Acute Cardiac Care