LEFT MAIN STEM CLOT: A MANAGEMENT DILEMMA

Abstract

SUMMARY

LMCA thrombus is a rare event and a management challenge as well. Here we report a case of 56 years old male presented with anterior wall myocardial infarction. Angiography showed clot in LMS and totally occluded LAD with dominant left system. Patient managed conservatively with thrombolytics followed by anti-thrombotic drugs. Patient responded to the treatment and discharged on 9^th day with repeat angiogram showing normal LMS and well patent large sized LAD. Currently he is on anti-ischemic and heart failure medication with good functional capacity.

BACKGROUND

During coronary angiography, it is assessed that prevalence of occlusion of the left main stem (LMS) coronary artery is around 5–7%.¹ LMS thrombus is a clinically rare event. In acute coronary syndrome patients, the incidence is estimated to be ?0.8%.²  According to the literature, we can treatment these patients with urgent coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI), anticoagulation using heparin or glycoprotein IIb/IIIa inhibitors, intracoronary thrombolysis, aspiration of thrombus as reperfusion strategies.³ The management choice of LMS thrombus usually depends on the severity of the disease. So far there are no clear guidelines for choosing the best management strategy for treating such patients.

CASE PRESENTATION

A 56 years old male, smoker presented in the emergency department of Punjab Institute of Cardiology, Lahore with history of chest pain of seven hours duration. He was diagnosed as a case of Acute anterior wall ST elevation  myocardial infarction. He was taken to the Cath Lab with intent of primary PCI. Angiography showed clot in Left Main Stem and totally occluded Left Anterior Descending Artery (LAD). Left Circumflex Artery was a dominant vessel, so PCI was not done due to the risk of thrombus shift into it. Opinion was sought from our chief surgeon, he refused due to very high-risk CABG.

INVESTIGATIONS:

ECG

ANGIO FILM

ECHO

At the time of admission echo was not done. After streptokinase, his bed side Echo demonstrated wall motion abnormalities in anterior septum with EF of 35 %.. No images available.

After 6 weeks follow up Echo was done Images shown below.

PATHOLOGY LABS

All labs were normal except for the mildly elevated white cell count and cardiac enzymes. During admission his renal function was mildly impaired which later on improved to normal.

TREATMENT

So we decided to manage him medically. Injection Streptokinase (the only thrombolytic available in our center) given. Patient developed cardiogenic shock and pulmonary edema, which was managed with ionotropic support and IV Lasix. Patient remained on ionotropic support for 1 week, he also received Inj. Enoxaprine 60 mg BD along with DAPT during hospital stay.  After seven days’ patient became stable, Ionotropic support tapered off. Check injection repeated, showed no clot in LMS and patent LAD without requiring stenting or surgery.

OUTCOME AND FOLLOWUP

After eight days’ patient discharged in stable condition. After two months of follow up patient visited the hospital. He was having good functional capacity, can climb two flight of stairs and doing well on medical management comprising of ARNI, DAPA and other anti-ischemic drugs.

DISCUSSION

Management of a LMS clot typically involves either CABG or PCI, depending on the patient's anatomy and clinical situation, with immediate aggressive medical therapy including anticoagulation and antiplatelet medications to prevent further clot formation; a "heart team" approach is crucial for decision-making for the best treatment strategy. Various people managed the patient in different ways based on the clinical scenario.

Johnsen et al managed their patient with using anticoagulation and dual anti-platelet therapy.⁴ Matta et al treated the patient using thrombus aspiration catheter, heparin and dual anti-platelet therapy.⁵ Marchese et al treated the patient with PCI using manual thrombus aspiration, super-selective adenosine and intracoronary bolus of abciximab followed by stenting of LMS to proximal LAD with drug eluting stent.⁶ Malik et al managed the patient with CABG after a heart team discussion^.7 Our patient did well with the conservative approach. Left ventricular function dropped but nevertheless a life was saved with a good functional capacity thereafter.

LEARNING POINTS / TAKE HOME MESSAGE

• Revascularisation with CABG and PCI is the standard treatment of LMS thrombus.
• Our patient responded to a conservative medical treatment strategy using thrombolytic followed by antithrombotic therapy.

Footnotes

Contributors: All authors were involved in the acute management of the patient and contributed to the writing and editing of this paper. AWKF, SN and JS were all involved in the planning of this case report. AWKF wrote the initial manuscript draft. AWKF and JS were involved in the initial diagnosis and treatment. AWKF and JS performed the angiographies and decided on the selected treatment strategy, SN performed Echocardiography.