A series of unfortunate events: chronic total occlusion, haemopericardium, atrial fibrillation, and cerebral ischemic stroke. Is optimal management of anticoagulation therapy (in this case) possible?

Abstract

Successful chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has been related to discordant benefits concerning clinical and quality life measures. We present a patient previously diagnosed with hypertrophic cardiomyopathy with left ventricular outflow obstruction referred for a CTO of the left anterior descending artery PCI. Crossing via left anterior descending artery was complicated by perforation resulting in haemopericardium (no evidence of tamponade; the patient remained hemodynamically stable). On subsequent days the patient presented with two asymptomatic paroxysmal atrial fibrilation (AF) episodes (de novo). In this patient’s case, the stroke’s risk factors did not mandate anticoagulation due to haemopericardium and arrhythmia duration of < 48 hours. Twenty-six hours after the second AF episode, the patient suffered a large ischemic stroke in the territory supplied by the right middle cerebral artery. Despite mechanical thrombectomy (MT), the patient died. Even though CTO PCI is an appealing choice in patients with complex coronary artery disease and chronic total occlusion, the risk still should not be underestimated. Another issue is assessing the thromboembolic risk associated with acute cardioversion of patients with AF estimated to be of < 48 hours duration — it is usually considered low. However, there is increasing evidence that short runs of AF confer a significant risk of stroke. Moreover, it was shown that, among patients undergoing MT for acute ischemic stroke, women had worse outcomes at 90 days.