Abstract 11420: Left Main Coronary Embolism in Association With Ostium Secundum Atrial Septal Defect Presenting as Acute Coronary Syndrome

BackgroundCoronary embolism is an uncommon but potentially life-threatening condition, which represents up to 3% of all acute coronary syndromes. Early recognition of this condition is important for successful management and to prevent recurrence.Case PresentationA 50-year-old man, with a past medical history of hereditary spherocytosis, presented with mid-sternal chest pain radiating to the left arm that started at rest 12 hours prior to admission. EKG showed normal sinus rhythm with no acute ST changes. Troponin level was 5.7 ng/ml (Ref=< 0.034) consistent with non ST-elevation myocardial infarction. Coronary angiography showed an area of non-flow limiting filling defect involving the left main coronary artery with an extension to the proximal left anterior descending and left circumflex (arrow in panel A).Case OutcomeGiven the location of the presumed thrombus, medical therapy was recommended initially. The patient was started on IV heparin and tirofiban drips, along with oral aspirin and clopidogrel. Cardiothoracic surgery was consulted and recommended close monitoring since the patient was hemodynamically stable. A transesophageal echocardiogram showed an ostium secundum atrial septal defect (ASD), measuring 0.9 cm x 0.6 cm. Lower extremity Duplex was negative for deep vein thrombosis, and hypercoagulability panel was negative. A repeat coronary angiogram after 72 hours of medical management showed complete resolution of the thrombus without any residual stenosis (panel B). The patient was discharged on apixaban, aspirin, and atorvastatin.ConclusionsWe present a rare case of left main coronary artery embolism, which was presumed to be from an ostium secundum ASD as the source. Management of coronary artery embolism is controversial with limited data. Paradoxical embolism should be considered in the differential diagnosis. Further studies are needed to determine the best therapy in these patients.