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A 38 year old woman with acute chest pain was admitted to the hospital. Positive troponins and electrocardiographic signs of anterior wall myocardial infarction during atrial fibrillation were found. Echocardiography (panel below) showed hypokinesia of the anterior wall and severe mitral stenosis (arrowhead; LV, left ventricle; SC, spontaneous contrast). Coronary angiography showed an occlusion of the mid left anterior descending artery (LAD) (panel A, upper row). Using the Guardwire Plus system (Medtronic Inc), the wire was positioned in the distal LAD and three aspirations during distal balloon inflation were performed resulting in complete reperfusion (TIMI-III flow) (panel B, upper row) of an angiographically normal appearing LAD (arrow) and normalisation of ST-T segments. The retrieved debris, a large irregular shaped particle (panel A, lower row, arrow), was histopathologically analysed and showed predominantly thrombus (T) with small but non-atherosclerotic parts of vascular media (M) and intima (I) (panel B, lower row, Mason’s trichrome). An additional stain for inflammation showed that CD-68 positive macrophages within this part of the retrieved intima were absent, suggesting absence of atherosclerotic coronary disease. It was hypothesised that the occlusion was due to a significant embolus derived from a prominent thrombus (arrow) found in the left atrial appendage as seen on transoesophageal echocardiography. Also massive spontaneous contrast (SC) was visualised in the left atrium. We suspect that the media and intima found in the aspirate were most likely obtained following traumatic passage of the aspiration catheter. The patient afterwards underwent mitral valve surgery as well as removal of the intra-atrial thrombus, and recovered well.
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