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The "crushing'' aortic prosthesis: a fatal acute myocardial infarction

Jeremias Bayon, Melisa Santas-Alvarez, Raymundo Ocaranza-Sanchez and Carlos Gonzalez-Juanatey

We report a 67 years old woman with prior mitral and aortic metallic prosthesis 14 days before, who came to the Emergency Room (ER) due to chest pain and hemodynamic instability, with dyspnoea in NYHA III and with an echocardiography showing hypocinesia of the anterior wall of the heart with low Left Ventricular Ejection Fraction (LVEF) of 35% and both prosthesis with normal function. The electrocardiogram showed sinus tachycardia and diffuse ST depression, diagnosing of Non ST-Elevation Myocardial Infarction (NSTEMI). We decided to perform an emergent coronary angiography. She had previously carried out a coronary angiography, five months earlier, with no evidence of Coronary Artery Disease (CAD). At the moment of the present NSTEMI, we observed high prosthesis implantation, with slow hemi-disc movement and evidence of thrombus in the Left Main (LM) with TIMI flow I, as well as in the left coronary sinus. An Intra-aortic Balloon pump was implanted and a thrombus aspiration catheter was used to improve the coronary flow. Then the TIMI flow improved, and we decided to fix the lesion with a 4.0×15 mm drug eluting stent of everolimus (SYNERGY™ Bioabsorbable Polymer Drug-Eluting Stent System from Boston Scientific) in the ostia of LM. The stent was implanted without complications, but few minutes later the patient went into refractory cardiogenic shock. The hemi disc of the prosthesis was literally crushing the stent and the TIMI flow was progressively worsen with associated thrombus. Finally the patient was exitus because of cardiac arrest with no response to the advance cardiopulmonary resuscitation. We present the report case and a brief review of the literature.