Methods:
An electrocardiogram (ECG) demonstrated ST-segment depressions in leads
V5-6 and T-wave inversions in leads II and III. Initial troponin levels
were elevated at 684 pg/mL, and he was also noted to have acute kidney
injury. A computed tomography angiogram ruled out aortic dissection but
revealed a 2.3 cm filling defect in the left ventricle, consistent with
a thrombus (Figure 1). After administration of morphine and diazepam,
the patient’s chest pain improved. He was started on a heparin infusion,
aspirin, clopidogrel, and atorvastatin.
Transthoracic echocardiography revealed a significantly reduced left
ventricular ejection fraction of 10-15%, grade III diastolic
dysfunction, and the presence of a left ventricular apical thrombus. A
repeat ECG showed no new ST elevations, but persistent ST depressions in
the high lateral leads and T-wave inversions in the inferior leads were
noted. The repeat troponin level increased to 10,970 pg/mL. Given these
findings, the decision was made to transfer the patient to the cardiac
catheterization laboratory for further evaluation and admit him to the
coronary care unit (CCU) for close monitoring, with a diagnosis of
non-ST elevation myocardial infarction (NSTEMI).
Coronary angiography revealed a normal right coronary artery (RCA)
proximally and mid-segment, but extensive clot burden and total
occlusion distally (Figure 2). The left main artery, left anterior
descending (LAD) artery, and left circumflex artery were free of
significant disease. A left ventriculogram showed no visible ventricular
thrombus, but left ventricular end-diastolic pressure (LVEDP) was
elevated at 33 mmHg.
A decision was made to proceed with mechanical thrombectomy. Heparin was
administered to maintain an activated clotting time of 300-350 seconds,
and the RCA was engaged with a Judkins Right 4 (JR4) 6-French guide
catheter. A balanced middleweight (BMW) coronary guidewire was used to
cross the thrombus and was placed in the distal posterior descending
artery. Multiple passes of mechanical thrombectomy were performed using
the Penumbra CAT RX device. The wire was then repositioned into the
right posterolateral ventricular branch, and another thrombectomy run
was completed.