Dear Label_Name,

Greetings! I hope you are well.

I am writing on behalf of an international publishing house, Science and Education Publishing, USA (http://www.sciepub.com).

Science and Education Publishing (SciEP) is a multidisciplinary open access publisher of Journals covering the fields of Science, Technology and Medicine. All SciEP publications are subject to high-quality peer review, editorial and production processes and are freely available online.

Welcome to the April, 2013 edition of SciEP newsletter, providing monthly summaries of articles on science & education related topics of interest to scientist and professionals. The mission of our journals is to provide an open access forum for publishing new findings on issues pertinent to scientific and academic field. We also invite you to submit original research papers, review articles, short reports, or case studies are considered for publication in our Multidisciplinary Journals.

American Journal of Public Health Research
DOI: 10.12691/ajphr-1-1-3

The Implementation of a Tele-Homecare System with Service Oriented Architecture and HL7 Message Transmission Standard
Ching-Sung Wang

American Journal of Medical and Biological Research
DOI: 10.12691/ajmbr-1-1-2

The Influence of Ethanol on Pyruvate Kinases Activity in Vivo, in Vitro, in Silico
Lelevich Sergey Vladimirovich, Khrustalev Vladislav Victorovich, Barkovsky Eugene Victorovich, Shedogubova Tatyana Aleksandrovna

American Journal of Medical Sciences and Medicine
DOI: 10.12691/ajmsm-1-1-1

Clinical and Histological Features in Wegener Granulomatosis
Li Cavoli Gioacchino, Passantino Rita, Bono Luisa, Tortorici Calogera, Ferrantelli Angelo, Giammarresi Carlo, Rotolo Ugo

American Journal of Infectious Diseases and Microbiology
DOI: 10.12691/ajidm-1-1-2

The Curse of Lymphatic Filariasis: Would the Continual Use of Diethylcarbamazine Eliminate this Scourge in Papua New Guinea?
Anne Lanham, Lillian Mwanri

We have released issues of some journals on February 2013.
American Journal of Public Health Research
American Journal of Medical Sciences and Medicine
American Journal of Medical and Biological Research
American Journal of Pharmacological Sciences
American Journal of Clinical Medicine Research
American Journal of Nursing Research
American Journal of Cancer Prevention
American Journal of Medicine Studies
American Journal of Infectious Diseases and Microbiology
American Journal of Cardiovascular Disease Research
American Journal of Biomedical Research
American Journal of Mechanical Engineering
American Journal of Microbiological Research
Journal of Preventive Medicine
American Journal of Food and Nutrition
American Journal of Hypertension Research
American Journal of Sports Science and Medicine
Journal of Cancer Research and Treatment
American Journal of Zoological Research
Journal of Biomedical Engineering and Technology
American Journal of Microbiological Research
Biomedical Science and Engineering

We are pleased to announce that submissions are now being accepted for peer review for all the journals across all our subject areas in SciEP.

Please submit your manuscript via our online submission system:
http://www.sciepub.com/author/signin

To unsubscribe from our mailing list, please click on the following link: unsubscribe

I am looking forward to hearing from you.

Kind regards,

David Rain
Email:join@sciepub.com
Science and Education Publishing (http://www.sciepub.com)

Label_Title

Dear Label_Name,

Greetings! I hope you are well.

I am writing on behalf of an international publishing house, Science and Education Publishing, USA (http://www.sciepub.com).

Science and Education Publishing (SciEP) is a multidisciplinary open access publisher of Journals covering the fields of Science, Technology and Medicine. All SciEP publications are subject to high-quality peer review, editorial and production processes and are freely available online.

Welcome to the April, 2013 edition of SciEP newsletter, providing monthly summaries of articles on science & education related topics of interest to scientist and professionals. The mission of our journals is to provide an open access forum for publishing new findings on issues pertinent to scientific and academic field. We also invite you to submit original research papers, review articles, short reports, or case studies are considered for publication in our Multidisciplinary Journals.

American Journal of Public Health Research
DOI: 10.12691/ajphr-1-1-3

The Implementation of a Tele-Homecare System with Service Oriented Architecture and HL7 Message Transmission Standard
Ching-Sung Wang

American Journal of Medical and Biological Research
DOI: 10.12691/ajmbr-1-1-2

The Influence of Ethanol on Pyruvate Kinases Activity in Vivo, in Vitro, in Silico
Lelevich Sergey Vladimirovich, Khrustalev Vladislav Victorovich, Barkovsky Eugene Victorovich, Shedogubova Tatyana Aleksandrovna

American Journal of Medical Sciences and Medicine
DOI: 10.12691/ajmsm-1-1-1

Clinical and Histological Features in Wegener Granulomatosis
Li Cavoli Gioacchino, Passantino Rita, Bono Luisa, Tortorici Calogera, Ferrantelli Angelo, Giammarresi Carlo, Rotolo Ugo

American Journal of Infectious Diseases and Microbiology
DOI: 10.12691/ajidm-1-1-2

The Curse of Lymphatic Filariasis: Would the Continual Use of Diethylcarbamazine Eliminate this Scourge in Papua New Guinea?
Anne Lanham, Lillian Mwanri

We have released issues of some journals on February 2013.
American Journal of Public Health Research
American Journal of Medical Sciences and Medicine
American Journal of Medical and Biological Research
American Journal of Pharmacological Sciences
American Journal of Clinical Medicine Research
American Journal of Nursing Research
American Journal of Cancer Prevention
American Journal of Medicine Studies
American Journal of Infectious Diseases and Microbiology
American Journal of Cardiovascular Disease Research
American Journal of Biomedical Research
American Journal of Mechanical Engineering
American Journal of Microbiological Research
Journal of Preventive Medicine
American Journal of Food and Nutrition
American Journal of Hypertension Research
American Journal of Sports Science and Medicine
Journal of Cancer Research and Treatment
American Journal of Zoological Research
Journal of Biomedical Engineering and Technology
American Journal of Microbiological Research
Biomedical Science and Engineering

We are pleased to announce that submissions are now being accepted for peer review for all the journals across all our subject areas in SciEP.

Please submit your manuscript via our online submission system:
http://www.sciepub.com/author/signin

To unsubscribe from our mailing list, please click on the following link: unsubscribe

I am looking forward to hearing from you.

Kind regards,

David Rain
Email:join@sciepub.com
Science and Education Publishing (http://www.sciepub.com)

Coronary Embolism in a Patient with Mechanical Mitral Valve: The High Cost of Anticoagulation Discontinuation

Laoufi Zaynab*, Lokman Hafsa, Benyass Aatif, Mouine Najat, Lakhal Zouhair

Cardiology Department, Mohamed V Military Hospital, Ibn Sina University Hospital, Faculty of Medicine and Pharmacy, Mohammed V University, Rabat, Morocco

Abstract: Coronary embolism is a non-atherosclerotic cause of acute coronary syndromes. It is frequently observed in patients with atrial fibrillation or prosthetic heart valves. We report the case of a 40-year-old woman with no cardiovascular risk factors but a history of mechanical mitral valve replacement, who had discontinued her vitamin K antagonist (VKA) therapy without medical supervision. She presented with sudden-onset, typical anginal chest pain at rest, described as retrosternal pressure radiating to the left arm and associated with dyspnea. Transthoracic echocardiography revealed an abnormality on the mitral prosthesis, and transesophageal echocardiography confirmed the presence of a thrombus. Coronary angiography identified a subocclusive thrombotic lesion in the mid-left anterior descending (LAD) artery, consistent with coronary embolism. The patient underwent successful manual thrombectomy without stent implantation.

Keywords: Coronary embolism, Prosthetic heart valve, Thrombectomy, Valve thrombosis

Received May 20, 2025; Revised June 22, 2025; Accepted June 30, 2025

Citation: Laoufi Zaynab, Lokman Hafsa, Benyass Aatif, Mouine Najat, Lakhal Zouhair, Coronary Embolism in a Patient with Mechanical Mitral Valve: The High Cost of Anticoagulation Discontinuation. American Journal of Medical Case Reports, 13 (6). 31-33. January 2025. doi:10.12691/ajmcr-13-6-1

1. Introduction

Acute coronary syndrome (ACS) is most commonly caused by atherosclerotic plaque rupture, which can lead to myocardial ischemia. However, non-atherosclerotic causes such as coronary embolism, though rare, should not be overlooked — particularly in patients with low cardiovascular risk profiles. Coronary embolism is an underrecognized cause of ACS, accounting for approximately 2.9% to 4.0% of cases in angiographic and autopsy series [1]. It can present with the same clinical and electrocardiographic features as classic atherothrombotic myocardial infarction, making diagnosis particularly challenging [2,3].

Atrial fibrillation, endocarditis, intracardiac thrombi, and the presence of mechanical prosthetic valves are conditions that predispose to coronary embolism. In patients with prosthetic heart valves, continuous anticoagulation is essential to prevent thromboembolic events. Poor adherence to anticoagulation therapy significantly increases the risk of coronary embolism.

Although rare, coronary embolism is associated with significant morbidity and a potentially severe prognosis, particularly in the absence of prompt diagnosis and management. Delayed recognition may result in larger infarcts, mechanical complications, or sudden cardiac death.

We report the case of a 40-year-old woman with a history of mechanical mitral valve replacement who had discontinued anticoagulation therapy for over three years. She presented with sudden-onset typical anginal chest pain at rest and was diagnosed with an acute coronary syndrome. Coronary angiography revealed a thrombotic occlusion of a coronary artery, that was successfully treated with manual thrombectomy. A diagnosis of coronary embolism was established.

2. Case Presentation

A 40-year-old woman with a history of mechanical mitral valve replacement for rheumatic mitral stenosis and concomitant tricuspid valve plasty performed nine years earlier was admitted for the management of acute chest pain at rest. The pain had started suddenly five hours before admission. It was described as severe, constrictive retrosternal discomfort radiating to the left arm, and was associated with dyspnea and sweating. The pain was continuous and not relieved by rest. Notably, the patient had discontinued her vitamin K antagonist (VKA) therapy three years earlier due to heavy menstrual bleeding. No medical consultation had been sought at the time, and she was not taking any other medications.

On examination, she was hemodynamically stable. Cardiac auscultation revealed an irregular rhythm and an audible mechanical valve click. The electrocardiogram (ECG) showed atrial fibrillation at 95 beats per minute, with negative T waves in the septal, lateral, and inferior leads. According to the patient, her atrial fibrillation had preceded the surgery, likely as a complication of rheumatic mitral stenosis and left atrial enlargement.

Troponin levels were elevated to 400 times the normal value, with the rest of the laboratory results being normal (Table 1).

Table 1. Initial Laboratory Findings at Admission

Given the clinical presentation suggestive of acute coronary syndrome (ACS), the patient was managed according to standard protocols. She received a loading dose of aspirin and clopidogrel. Serial troponin measurements were performed throughout her hospitalization. (Figure 1).

Figure 1. Graph showing the kinetics of the patient's troponin levels during hospitalization.

Transthoracic echocardiography demonstrated left ventricular dilatation with apical akinesia and a moderately reduced ejection fraction estimated at 39%. Dysfunction of the mechanical mitral valve was suspected. Both atria were dilated, whereas the right ventricle exhibited normal dimensions and preserved systolic function. Transesophageal echocardiography identified a mobile echogenic mass attached to the ventricular side of the mitral prosthesis, highly suggestive of a thrombus (Figure 2).

Coronary angiography revealed a subocclusive thrombotic lesion in the mid-left anterior descending (LAD) artery, with preserved distal flow, suggestive of coronary embolism (Figure 3).

Figure 2. Transesophageal echocardiographic images showing a mobile thrombus attached to the ventricular side of the mechanical mitral valve. LA: Left Atria, LV:Left ventricle

Figure 3. Coronary angiography showing a subocclusive thrombotic stenosis of the mid-left anterior descending (LAD) artery

The remainder of the coronary tree appeared angiographically normal. A manual thrombectomy was performed in the LAD, resulting in successful thrombus extraction and restoration of normal coronary flow, along with the administration of a GPIIb/IIIa receptor inhibitor. No stent was implanted, as no underlying atherosclerotic lesion was identified. Anticoagulation therapy with a vitamin K antagonist (VKA) was reinstated, accompanied by thorough patient education and regular INR monitoring.

3. Discussion

Embolic phenomena in the coronary circulation are rare under normal physiological conditions due to the protective anatomy of the coronary arteries and the shielding effect of the aortic valve cusps during systole. However, the risk of coronary embolism increases significantly in patients with atrial fibrillation, prosthetic heart valves, infective endocarditis [4], or hypercoagulable states. In such cases, ineffective anticoagulation with International Normalized Ratio (INR) levels outside the therapeutic range or discontinuation of vitamin K antagonists (VKAs) may predispose to thrombus formation. Our patient presented a high thrombotic risk due to the presence of a mechanical mitral valve, atrial fibrillation, and a history of anticoagulation discontinuation. Clinically, coronary embolism typically presents as an acute coronary syndrome in patients with low cardiovascular risk but known thrombotic risk factors. Biologically, a marked elevation in cardiac biomarkers is often observed. However, electrocardiography (ECG) and transthoracic echocardiography (TTE) generally do not allow differentiation between coronary embolism and atherosclerotic acute coronary syndrome.

Transesophageal echocardiography (TEE) remains the key diagnostic tool, allowing detailed visualization of the heart valves and detection of intracardiac thrombi. Cardiac catheterization may reveal atypical findings, such as occlusion of one or more coronary vessels in the absence of underlying atherosclerosis — specifically, no evidence of unstable plaques, dissections, or mural thrombi.

To date, no established treatment guidelines exist [5]. In our patient’s case, thrombectomy was carefully performed. Coronary thrombectomies are infrequently performed due to the technical expertise required and the significant risk of complications associated with the procedure. Common complications include coronary dissection, failure in cases of adherent thrombus with a no-reflow phenomenon, systemic embolism, and thrombus migration [6]. The addition of a glycoprotein IIb/IIIa receptor inhibitor is often indicated [7] to enhance thrombectomy effectiveness.

Another key consideration in managing these patients is whether or not to place a stent [8]. In cases of failure or partial success, balloon angioplasty combined with stent placement, alongside anticoagulant and antiplatelet therapy, can be beneficial [9].

In our patient’s case, no stent was implanted, as the coronary vessels appeared smooth and showed no signs of atherosclerosis. Furthermore, distal flow beyond the lesion was preserved (TIMI III). Stent implantation would have necessitated lifelong anticoagulation, which posed a significant risk given the patient’s history of treatment interruption.

Maintaining effective anticoagulation therapy is essential to prevent embolic events, especially in patients with atrial fibrillation [10]. In our patient’s case, direct oral anticoagulant (DOAC) therapy was proposed due to its proven efficacy and ease of management compared to vitamin K antagonists (VKAs) [11], but the treatment was declined by the patient because of financial constraints. Recent studies and meta-analyses [12] have demonstrated that DOACs are as effective as VKAs in preventing thromboembolic events in patients with atrial fibrillation secondary to valvular heart disease, while offering a comparable or improved safety profile—particularly with a lower risk of intracranial hemorrhage—and greater ease of use.

4. Conclusion

Coronary embolism should be suspected in any case of acute coronary syndrome occurring in a patient with low cardiovascular risk but a high thrombotic risk . Accurate diagnosis relies on integrating the clinical context with advanced imaging modalities, such as transesophageal echocardiography, which can identify intracardiac sources of emboli, and coronary angiography, which remains the gold standard for definitive confirmation. The management of coronary embolism must be carefully individualized, taking into account the patient’s coronary anatomy and the angiographic features of the culprit lesion.

References

[1]   | Shibata T, Kawakami S, Noguchi T, et al. Prevalence, clinical features, and prognosis of acute myocardial infarction attributable to coronary artery embolism. Circulation. 2015; 132(4): 241–250.
[2]   | Karakoyun S, Gürsoy MO, Kalçık M, Yesin M, Özkan M. A case series of prosthetic heart valve thrombosis-derived coronary embolism. Turk Kardiyol Dern Ars. 2014 Jul;42(5):467-71.
[3]   | Lacey MJ, Raza S, Rehman H, Puri R, Bhatt DL, Kalra A. Coronary Embolism: A Systematic Review. Cardiovasc Revasc Med. 2020 Mar; 21(3): 367-374.
[4]   | Garvey GJ, Neu HC. Infective endocarditis—An evolving disease: A review of endocarditis at the Columbia-Presbyterian medical center, vol. 57; 1978; 1968–73 Medicine (Baltimore).
[5]   | Budavari AI, Glenn TJ, Will KK, Askew JW, Fortuin FD. A case of simultaneous pulmonary embolism and acute myocardial infarction secondary to a previously undiagnosed patent foramen ovale. J Hosp Med United States 2009; 4: E5–9.
[6]   | Hernandez F, Pombo M, Dalmau R, Andreu J, Alonso M, Albarran A, et al. Acute coronary embolism: angiographic diagnosis and treatment with primary angioplasty. Catheter Cardiovasc Interv United States 2002; 55 :491–4.
[7]   | Adnan G, Singh DP, Mahajan K. Coronary Artery Thrombus. [Updated 2022 Oct 3]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-.
[8]   | Kotooka N, Otsuka Y, Yasuda S, Morii I, Kawamura A, Miyazaki S. Three cases of acute myocardial infarction due to coronary embolism: treatment using a thrombus aspiration device. Jpn Heart J Japan 2004; 45: 861–6.
[9]   | Giri S, Hwang I, Alsafwah S. A case of left main coronary artery embolus further embolising to the left anterior descending artery. BMJ Case Rep England 2014; 2014.
[10]   | Acikel S, Dogan M, Aksoy MMN, Akdemir R. Coronary embolism causing non-ST elevation myocardial infarction in a patient with paroxysmal atrial fibrillation: treatment with thrombus aspiration catheter. Int J Cardiol Netherlands 2011:e33–5.
[11]   | Yokoyama Y, Briasoulis A, Ueyama H, Mori M, Iwagami M, Misumida N, Takagi H, Kuno T. Direct oral anticoagulants versus vitamin K antagonists in patients with atrial fibrillation and bioprosthetic valves: A meta-analysis. J Thorac Cardiovasc Surg. 2023 Jun; 165(6): 2052-2059. e4.
[12]   | de Souza Lima Bitar Y, Neto MG, Filho JAL, Pereira LV, Travassos KSO, Akrami KM, Roever L, Duraes AR. Comparison of the New Oral Anticoagulants and Warfarin in Patients with Atrial Fibrillation and Valvular Heart Disease: Systematic Review and Meta-Analysis. Drugs R D. 2019 Jun; 19(2): 117-126.