Sub-acute anterior myocardial infarction due to the discontinuation of warfarin in a patient with aortic valve prosthesis: what is the best treatment

Acute myocardial infarction (MI) is a common entity in patients due to the atherosclerotic plaque rupture. But there are other susp10cious etiologic reasons that lead to coronary embolism such as intra-cardiac prosthesis, infective endocarditis, mural thrombus or a cardiac tumor [1-7]. Even if the patient did not use warfarin, the real reason for acute myocardial infarction whether embolism or atherosclerotic plaque ruptures should be revealed in order to decide optimal treatment option. Intravascular ultrasonography and optical coherence computed tomography are very useful to diagnosis so which treatment is the best; thrombolysis, angioplasty or stenting. Previous cases of coronary emboli in association with prosthetic mechanical valves have been reported previously but the treatment is controversial [8-16]. We present a patient who had a mechanical aortic valve and was admitted to the hospital for a sub-acute anterior ST elevation myocardial infarction due to the discontinuation of warfarin. Case A 58-yearold male presented with severe retrosternal chest and back pain radiates to his left arm for 20 hours was admitted to our coronary care unit. His symptoms were resolved on admission. He had previous mechanical aortic valve implantation nine years earlier because of a rheumatic aortic valve. The patient did not have a history of traditional cardiovascular risk factors except smoking (1 pack a day) and hypertension. No other comorbidities are present. His familial medical history is otherwise unremarkable. Pulse rate was 68/bpm, regular, arterial blood pressure was 110/70 mmHg, lungs were clear breath rate was 18/pm, no murmur on physical examination. Systolic ejection murmur grade 2/6 on the second right parasternal space and a mechanical valve click was heard with the cardiac auscultation. The electrocardiography (ECG) revealed ST-segment elevation in the precordial leads consistent with sub-acute anterior myocardial infarction (MI); ST Acute myocardial infarction (MI) is a common entity in patients due to the atherosclerotic plaque rupture or coronary embolism. We present a patient who had a mechanical aortic valve and was admitted to the hospital for a sub-acute anterior ST elevation myocardial infarction due to the discontinuation of warfarin. In case of persistent thrombus formation despite aggressive antithrombotic and anticoagulant therapy, thrombus aspiration, angioplasty and stenting should be preferred rather than conservative approach.