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.