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Coronary artery embolism complicating heart valve surgery: role of mechanical thrombectomy
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An 82 year old woman underwent mitral valve annuloplasty and aortic valve replacement with a bioprosthesis. Sudden pronounced ST elevation was recorded on cardiac monitor while she was still intubated and sedated within 24 hours of the operation. Preoperative coronary angiogram was normal. Immediate cardiac catheterisation showed mid left anterior descending artery (LAD) embolic occlusion with TIMI 0 flow (panel A). Using an 8F XB3.5 guiding catheter, the occlusion was crossed with a 0.014 inch guidewire. Mechanical thrombectomy was performed using the Possis angiojet rheolytic thrombectomy system (panel B) The system consists of a 5 French angiojet catheter, a pump set, and a drive unit. The pump set, powered by the drive unit, delivers pressurised saline to the catheter. Powerful, high velocity saline jets create suction current at the catheter tip resulting in rapid mechanical thrombolysis and removal via the catheter's effluent lumen. The pro-arrhythmic venturi effect produced by the system necessitates the use of a temporary pacing wire. Adjunctive balloon angioplasty and stenting was performed. TIMI 3 flow was restored. The final angiogram is shown in panel C. This case highlights the niche role of mechanical thrombectomy devices in thrombo-occlusive coronary artery disease when both thrombolytics and glycoprotein IIb/IIIa receptor antagonists are contraindicated.