Comment on “Dual Prosthetic Heart Valve Presented with Chest Pain: A Case Report of Coronary Thromboembolism”

We have recently read with great interest the case report by S. Wongrakpanich et al. describing a patient with a history of dual prosthetic heart valves and atrial fibrillation who developed coronary embolism (CE) due to inadequate anti-coagulation [1]. Thanks are due to the authors for their contribution of the present report including a rare complication of prosthetic valve thrombosis (PVT). On the other hand, we want to make essential criticism regarding some major drawbacks in the management of the patient. CE is a rare cause of acute coronary syndrome (ACS) in patients with prosthetic heart valves. The majority of patients with prosthetic heart valve who were admitted with ACS had non-ST elevation ACS rather than ST segment elevation ACS [2]. The information in the literature about this complication is scarce and mainly based on case reports. There is a controversy regarding the treatment of patients with CE. In the current literature, intracoronary or intravenous thrombolytic therapy (TT), stent implantation, and embolectomy were performed as reperfusion strategies, but there is no consensus regarding the optimal treatment. In the case report presented by S. Wongrakpanich et al. a 54-year-old man with two ball-caged metallic prosthetic valves in mitral and aortic position was admitted with ACS. He had a history of left embolic stroke 15 years ago and international normalized ratio on the last admission was subtherapeutic. The authors performed emergent coronary angiography (CAG) before evaluation of the prosthetic valve with transthoracic (TTE) or transesophageal echocardiogra-phy (TEE). CAG revealed a thrombus image in the middle segment of the circumflex coronary artery which was aspirated successfully. The underlying vessel structure was normal which was consistent with a coronary embolism. So they performed TTE which revealed acceptable pressure gradients across both mechanical prostheses. First of all, the major concern regarding the management of this patient is that, even with the gradients and orifice area being within normal limits, TTE is usually uncapable of demonstrating the presence of nonobstructive thrombus on the prosthetic valves, necessitating TEE examination. Since the patient had aortic prosthesis, urgent conventional CAG without TEE examination carried a high risk of new potential thromboembolism due to catheter manipulation during CAG. Although the patient was not complicated with new thromboembolism, it would be better if they performed CAG just after TEE findings suggested that catheter intervention would be safe. Another noteworthy issue regarding the management of the patient is that, when a patient …