Usui Rena, Mutsuga Masato, Narita Yuji, Tokuda Yoshiyuki, Terazawa Sachie, Ito Hideki, Uchida Wataru, Usui Akihiko
Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, Japan.
Surg Case Rep. 2021 Oct 14;7(1):223. doi: 10.1186/s40792-021-01296-3.
Acute coronary syndrome (ACS) caused by mechanical obstruction of the coronary artery with a vegetation is extremely rare but associated with high mortality. The optimal management strategy of this condition remains controversial because of its scarcity. We experienced a case of sudden circulatory collapse due to mechanical occlusion of the left main coronary trunk with a vegetation.
A 68-year-old woman with aortic and mitral valve infective endocarditis suffered sudden dyspnea followed by heart arrest while awaiting surgery. Despite treatment with adequate antibiotic therapy, she had had multiple embolic infarctions and ruptured infectious cerebral aneurysms. We conducted transcatheter arterial embolization of the aneurysm and postponed the cardiac surgery due to residual aneurysmal blood flow. She suffered sudden cardiac arrest, and extracorporeal membrane oxygenation was applied after cardiopulmonary resuscitation. An echocardiogram revealed diffuse severe hypokinesis, and emergency coronary angiography was performed under suspicion of ACS. It revealed obstruction of the left main coronary trunk by a vegetation. Emergent cardiac surgery was performed. A vegetation had occluded the left coronary orifice. Aortic and mitral valve replacement with coronary artery bypass to the left antero-descending branch was performed. Regarding her cardiac function, she still required extracorporeal membrane oxygenation after surgery. She passed away 19 days after surgery due to multiple organ failure.
ACS caused by mechanical obstruction of the coronary artery with a vegetation is rare but associated with high mortality. When circulatory collapse acutely occurs in patients with aortic valve infective endocarditis, we should suspect acute coronary artery obstruction. Urgent coronary angiography is mandatory to rescue the patient while preparing for emergency surgery.
由赘生物导致冠状动脉机械性阻塞引起的急性冠状动脉综合征（ACS）极为罕见，但死亡率很高。由于其病例稀少，这种情况的最佳治疗策略仍存在争议。我们遇到了一例因左主干冠状动脉被赘生物机械性阻塞而导致突然循环衰竭的病例。
一名68岁患有主动脉瓣和二尖瓣感染性心内膜炎的女性在等待手术期间突然出现呼吸困难，随后心脏骤停。尽管接受了充分的抗生素治疗，但她仍发生了多次栓塞性梗死和感染性脑动脉瘤破裂。由于动脉瘤仍有残余血流，我们对动脉瘤进行了经导管动脉栓塞，并推迟了心脏手术。她随后发生心脏骤停，心肺复苏后应用了体外膜肺氧合。超声心动图显示弥漫性严重运动减弱，因怀疑ACS进行了急诊冠状动脉造影。结果显示左主干冠状动脉被赘生物阻塞。遂进行了急诊心脏手术。一个赘生物阻塞了左冠状动脉口。进行了主动脉瓣和二尖瓣置换，并对左前降支进行了冠状动脉搭桥术。关于她的心脏功能，术后仍需要体外膜肺氧合支持。她在术后19天因多器官功能衰竭去世。
由赘生物导致冠状动脉机械性阻塞引起的ACS罕见但死亡率高。当主动脉瓣感染性心内膜炎患者急性发生循环衰竭时，应怀疑急性冠状动脉阻塞。在准备急诊手术的同时，紧急冠状动脉造影对于挽救患者至关重要。
