A 50-year old pat. with h/o smoking and mediastinal irradiation for Hodgkin's disease some 25years go was admitted to the chest pain unit with NSTEMI. Cath showed a thrombus in the left main stem with TIMI III flow. Aggressive antiplatelet therapy was instituted and repeat angio was performed four days later showing a size reduction of the thrombus.
Given the fact that this patient has a low Syntax score what would you recommend?
Watchful waiting with antiplatelet therapy and repeat angio in several weeks or months or DES therapy or double mammary bypass?
Why you prefer antiplatelet terapy? There was contraindication for conventional thrombolic therapy? If the thrombus was solved with thrombolitic, I think that percutaneous or surgical therapy was not necessary. In your case if the coronary flow is good I keep the antiplatelet therapy until thrombus desapear. I think that any invasive approach is indicated if the organized thrombus cause permanent obstruction in left main.
The therapeutic regimen was instituted in the cath lab and consisted of Tirofiban, Prasugrel and Heparin i.v. I am not aware of any contraindications to thrombolysis in this patient.
HI
We had such a case. Young lady presenting with on and off chest pain, troponin and CKMB rise, ST changes but no ST elevation. Coronary angiography revealed thrombus in LMCA with TIMI 3 flow both in LAD and LCx. Most probably she had some kind of predisposition to thrombosis and/or minor endothelial damage. WE started tirofiban and infused for 48 hours with asa and clopidogrel and low dose LMWH. Kept in the CCU and after 2 days repeated angiography. Thrombus comletely resolved without any complication, normal LV function. Discharged teh lady, no recurrence in follow up continued double antiplatelet theraphy for some time.
Best Wishes
We have a case quite similar resolved with a stent plus prasugrel and tirofiban also.After a week the thrombus dissappeared at angio.I would add angiojet with thrombolitycs in the bag.Left main has such a diameter that if you have good TIMI flow you should wait .
In the absence of stenosis, there is no role for stenting or angioplasty. The thrombus needs lysis and antiplatelets to prevent recurrence. Needs to work up for prothrombotic states like APLA syndrome in which case longterm warfarin therapy may be indicated
Dear colleagues,
thank you for your input. The patient underwent control angiography yesterday and the thrombus had disappeared completely without any further intervention. Pat will be discharged on antiplatelet regimen and we will ask for a workup for coagulation disorders.
Great news,
What a relief for you and the patient.
Thank you for sharing this case and the outcome with us.
Best Wishes
Dr Cemil Izgi
I agree with Raghuram that we should not stent this patient,I would use a thrombuster upfront ,extract the clot and then give DAP with GP2b/3a
I think that another exploration such IVUS or coronary CT scan may be helpfull
We had a similar case (left main TH with TIMI III flow). We tried 48 h of DAPT + GPI + UFH and repeated angio. Unfortunately the TH was still there. We then positioned 1 Filterwire in LAD and 1 in Circumflex before to apply thrombus aspiration. The thrombus then disappeared from left main (in part aspirated, in part retrieved by the LAD filter). The case report is published (is in attachment).
Unfortunately is in italian but pictures are very explicative...
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