Discussion:
Myocardial Infarction due to simultaneous double vessel thromboses is a rarely reported event [1], probably representing 2.5% among primary percutaneous coronary interventions [2]. Nearly one-third presents with cardiogenic shock, and about one-fourth requires IABP insertion [2]. Contributing factors include inflammatory states, hemodynamic instability, hypercoagulable conditions, prolonged coronary vasospasm, coronary embolism, and hyperhomocysteinemia[2]. However, in more than half of patients, no leading cause can be identified [2]. In our case, no prothrombotic factor was found, and probably heavy tobacco use in such a relatively young age was highly thrombogenic.
An immediate PCI was attempted as recommended by the ACCF/AHA and ESC guidelines, irrespective of the time delay from symptoms onset; when PCI has failed, emergency CABG was indicated and done according to the same recommendations(Class I, Level B)[3, 4]. Routine use of thrombo-aspiration is still not endorsed by the ESC [4]. Our patient was young enough to withstand an extensive surgery, and this proved beneficial. Blood clots were adequately removed from the LAD and the PDA without any crush effect, micro-embolization, or no-reflow phenomenon that may accompany percutaneous therapy. In addition, revascularization using both mammary arteries was successful. This is proven to have the best long-term survival rate [5]. The patient’s LAD and LIMA graft were patent on coronary scanner 10 months after the operation despite a theoretical competitive flow. The absence of flow through the completey-occluded-RCA allowed unimpeded flow through RIMA, which proved to be long enough to reach the PDA, and remained patent ten months after surgery. As far as we know, no such reported case was treated surgically; we report a successful surgical management with optimal outcome ten months after surgery.