Acute Myocardial Infarction in a Young Adult with an Atrial Septum Defect

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Slide 1 : Acute Myocardial Infarction in a Young Adult with an Atrial Septum DefectPernencar S., Mota P. Costa M., Leitão-Marques A. Case Report
Slide 2 : LCx LAD LMCA A 41 year old male, non-smoker without cardiovascular risk factors, came to our facility on May 2006 with severe chest pain of 1 hour duration. The patient was transported immediately to our cath lab due to acute myocardial infarction (lateral ST segment elevation). The entire preparation and transporting process took approximately 30 minutes. Angiography:1) LMCA normal 2) LAD normal 3) LCX was totally occluded in its proximal segment (Figure 1). 4) RCA was a non-dominant vessel, with TIMI 1 flow and without a clear significant stenosis (Figure 2).
Slide 3 : LAD LCX LMCA Figure 1
Slide 4 : RCA Figure 2
Slide 5 : Procedure:According to angiographic findings, we decided to open only the recent culprit lesion. The patient was given 5000UI of unfractionated heparin and a GPIIbIIIa inibitor was started. The LCX lesion was crossed with a guidewire (Figure 3), pre-dilated with a balloon, and stented with a 3.0x18mm Axxion Stent proximally and a 2.75x18mm Axxion Stent at the proximal marginal branch lesion. The overall procedure had a good final result (Figure 4). Repeat angiography of the RCA no longer showed "slow-flow”, suggesting a total resolution of embolic cause (Figure 5).
Slide 6 : LCx Figure 3
Slide 7 : LCx ST Figure 4
Slide 8 : RCA RPL PDA Figure 5
Slide 9 : Further studies were directed to find out the etiology of this thromboembolic phenomena: a) Blood tests to identify specific inherited disorder of thrombophilia, such as activated protein C resistance, mutation in the prothrombin gene, deficiency of protein C, protein S and antithrombin and homocysteinemia were normal. b) Transesophageal Color-Doppler echocardiography provided excellent visualization of defect of the atrial septum involving the fossa ovalis, suggesting large patent foramen ovale with spontaneous shunt (left-to-right atrium) (Figure 6).
Slide 10 : RA LA IVC SVC Figure 6
Slide 11 : Decision was made towards closure of atrial septal defect by percutaneous technique using an Amplatzer device. The correct position of the device was confirmed by fluoroscopic and transesophageal echocardiographic imaging guidance, before it was released (Figure 7 & Figure 8).
Slide 12 : RA LA Figure 7
Slide 13 : Figure 8
Slide 14 : Conclusion:The patient had an uneventful course in the wards and was subsequently discharged two days after the procedure. Comments:1) Acute coronary syndrome in the setting of a young adult must raise suspect of a possible thromboembolic phenomena; 2) Percutaneous closure of atrial septal defect with Amplatzer device is a safe, low cost and well established procedure.

 


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