A Rare Case of Embolic ST-Elevation Myocardial Infarction in an Adult Patient With Repaired Hypoplastic Left Heart Syndrome

Abstract

A 24-year-old male with past medical history of hypoplastic left heart syndrome and staged reconstructive surgery in infancy culminating in the Fontan circulation presented to the hospital with a chief complaint of chest pain described as an "elephant sitting" on his chest. Initial 12-lead electrocardiogram revealed 2-mm ST segment elevation in inferior leads, 3-mm ST-segment elevation in anterolateral precordial leads V3 and V4, and 2-mm ST-segment elevation in V5 and V6, with right axis deviation. He was transported emergently to the cardiac catheterization laboratory where coronary angiography revealed complete occlusion of multiple anomalous branches of the right coronary system with hazy appearance suggesting the presence of thrombotic material. An aspiration catheter was used successfully to reestablish TIMI grade III flow. The patient was treated with aspirin, brilinta (ticagrelor), and anticoagulation with vitamin K antagonism to prevent recurrent thromboembolic complications.

Intracoronary recombinant tissue plasminogen activator in an infant with hypoplastic left heart syndrome and complete left main coronary artery thrombosis

“…Another possible treatment for coronary thromboembolism is thrombus aspiration. This technique was previously reported in an infant and an adult with HLHS . Noonan et al reported a near complete occlusion of the distal right main coronary artery in a 3‐year‐old child with HLHS .…”

“…The thrombus was aspirated successfully via transcatheter approach . Another report described successful aspiration of thromboembolism from the RCA in a 24 year old patient with HLHS …”

“…6 Another report described successful aspiration of thromboembolism from the RCA in a 24 year old patient with HLHS. 16 Due to the evidence of increased cardiovascular system thrombosis (native ascending aorta, LV cavity, and coronary artery), which seems to be unique for patients with HLHS, 5-9 our current practice for thromboembolic prevention in such a vulnerable population must be rethought. A more aggressive approach aiming at different anti-thrombotic pathways must be considered.…”

Coronary artery embolism in a patient with Fontan palliation: a rare complication

“…On review of the literature, we found at least four cases of coronary artery thromboembolism reported in this patient population, with ages varying between 17 and 24 years. [3][4][5][6] Two of them were born with hypoplastic left heart syndrome, and the other two were diagnosed with pulmonary atresia and tricuspid atresia, respectively. [3][4][5][6] Chest pain with ST-segment changes on electrocardiogram was the presenting complaint leading to coronary angiogram in all cases.…”

“…[3][4][5][6] Two of them were born with hypoplastic left heart syndrome, and the other two were diagnosed with pulmonary atresia and tricuspid atresia, respectively. [3][4][5][6] Chest pain with ST-segment changes on electrocardiogram was the presenting complaint leading to coronary angiogram in all cases. While one underwent medical management with warfarin and aspirin, the other three patients required percutaneous coronary intervention, which included balloon angioplasty and thrombectomy.…”