Typical clinical presentation of acute myocardial infarction and confusing coronary angiography: A case report and literature review of coronary embolism

The purpose of this article is to discuss the characteristics, diagnosis, treatment, and outcomes of cases of multiple coronary embolism (CE) highly suspected to be caused by a dislodged aneurysm of the ventricular membranous septum (AVMS) thrombus. PATIENT CONCERNS: A 35-year-old man was rushed to the Chest Pain Center of Taicang TCM Hospital Affiliated to Nanjing University of Chinese Medicine for sudden onset of chest pain. The patient had severe and persistent chest pain without relief, accompanied by sweating throughout the body. DIAGNOSIS: An electrocardiogram showed ST-segment elevation in the inferior wall leads, and blood tests suggested elevated troponin I levels. The initial diagnosis was acute ST-segment elevation myocardial infarction. Emergency coronary angiography revealed complete occlusion of the first diagonal branch, thrombolysis in myocardial infarction grade 0 flow, and smooth remaining vessels. Complete occlusion of the left anterior descending artery unexpectedly occurred during interventional treatment. Postoperative cardiac ultrasonography revealed the presence of a thrombus within the AVMS and in the apical portion of the heart. The final diagnosis was a CE. INTERVENTIONS: Intraoperatively, the diagonal branch occluded segment was dilated with a balloon and intracoronary administration of tirofiban and nitroglycerin. Postoperatively, antithrombotic therapy (aspirin, clopidogrel, and rivaroxaban) was administered. OUTCOMES: Ten days after admission, a repeat coronary angiography showed complete restoration of left anterior descending artery flow on its own, balloon dilation was again performed on the diagonal branch, and flow was restored to thrombolysis in myocardial infarction grade 1. Six months later, the intracardiac thrombus disappeared on repeat cardiac ultrasound. LESSONS: AVMS is a potential source of embolism in patients with CE. CE has features that distinguish it from atherosclerosis, and a timely and correct diagnosis can help improve patient clinical outcomes.