Abstract 4371535: Successful Surgical Intervention in a Rare Embolic MI with Severe Bioprosthetic Aortic Valve Stenosis, A Case Report

Abstract

Introduction: Bioprosthetic valves are widely used for aortic valve replacement (AVR) and confer an excellent hemodynamic profile and reduced risk of thrombosis, but valve degeneration is a common complication. Here we present a rare manifestation of aortic valve degeneration initially presenting as heart failure, ultimately developing SCAI stage D/E cardiogenic shock due to embolic MI, and successfully treated surgically. Description of Case: A 38 year old male with a history of bioprosthetic AVR presented initially with palpitations. He was found to be in atrial fibrillation with rapid ventricular response. He subsequently developed sudden severe sub-sternal chest pain radiating to his left shoulder with new ST-elevations in the anteroseptal, anterolateral, and inferior leads on ECG. Emergent coronary angiogram showed acute embolic occlusion of the mid left anterior descending (LAD) and distal left circumflex arteries. Thrombectomy and Balloon Angioplasty were attempted unsuccessfully and an intra-aortic balloon pump (IABP) was placed. Ultimately the Cardiogenic Shock Team was activated, and deliberated endovascular vs surgical approaches. Patient was emergently taken to the OR for LAD thrombectomy, LV thrombectomy, a possible single-vessel coronary artery bypass graft (CABG) to the LAD, possible LAA closure, and a redo surgical AVR. This surgical intervention was ultimately successful. Discussion: This case demonstrates multiple complications of a patient with a bioprosthetic aortic valve. Out of the many treatment options for bioprosthetic valve degeneration, although PCI was initially prioritized, CABG was deemed as the best option as it provides a durable revascularization and bypasses the mLAD lesion that was not amenable to PCI. This case is one of a kind in today's literature as emergency CABG are overall on the decline and a concurrent AVR has not been reported. In these cases, restoration of blood flow is of utmost priority, and patients with evidence of ongoing ischemia post PCI should be offered an emergency CABG. Conclusion: This case shows an atypical case of refractory stemi and worsening cardiogenic shock due to a coronary embolus. The decision to perform an emergency single vessel CABG and AVR requires a nuanced understanding of the limitations between transcatheter and surgical approaches. There remains lack of RCT data comparing these approaches in these conditions nor any RCT comparing medical stabilization with delayed surgery.