Successful management of ostial left main thrombus by systemic thrombolysis

Abstract

A 43-year-old white male, obese (BMI = 43.2), heavy smoker (60 cigarettes/day), arrives at the hospital in a stable non-ST-segment elevation myocardial infarction (NSTEMI) setting [chest pain which started 4 h prior to his arrival, electrocardiogram (ECG) showing negative T-waves in inferior leads and flattened T-waves in lateral leads, troponin elevation at 14.70 ng/mL, normal echo]. After he received the standard pharmacological treatment (double antiplatelet treatment, anticoagulant, β-blocker, nitrates) plus GP IIb/IIIa inhibitor Tirofiban, the patient became asymptomatic, so we decided to follow an early-invasive strategy. Coronary angiography showed an ostial left main (LM) thrombus (70% obstruction), normal left anterior descendent artery, circonflex, and right coronary artery (Panel A). Electrocardiogram did not change during and after the intervention and maintained the initial pathological presentation, that of inferolateral ischaemia (Panel B). We switched the GP IIb/IIIa inhibitor to abciximab. From this point on we had two possible strategies: On the fourth day, thrombus was still in place, as multislice computed tomography also confirmed (Panel C). Biology showed normal cholesterol and negative tests for thrombophylia or platelet dysfunction. We decided to stop abciximab and to perform systemic thrombolysis on the next day, before an eventual angioplasty.