Uncommon Etiology of ST-elevation Myocardial Infarction: Behçet's Disease-Induced Coronary Aneurysm
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A 33-year-old man with Behçet's disease (BD) presented with new retrosternal chest pain and was transferred for primary percutaneous coronary intervention (PCI) due to inferior ST-segment elevation myocardial infarction. Coronary angiography showed aneurysmal dilation of the left coronary system and ectasia of the right coronary artery (RCA), which had a high thrombus burden and slow flow.
Thrombus aspiration was performed with an Export Advance aspiration catheter (Medtronic), and a long red thrombus was removed. Intracoronary tirofiban was administered from the aspiration catheter, but no stent was placed due to the patient’s age, aneurysmatic arteries, and a potential relationship with BD. In the cardiac intensive care unit, intravenous tirofiban and a heparin drip were used to achieve a target activated clotting time of 250 seconds. Rheumatology consultation confirmed active BD, leading to high-dose pulse steroids and cyclophosphamide treatment.
The patient was closely monitored for 2 weeks and received triple therapy with aspirin, clopidogrel, and apixaban for 1 month. Follow-up angiography at the third month showed regression of his RCA ectasia with distal Thrombus in Myocardial Infarction-3 flow. Echocardiography demonstrated a left ventricular ejection fraction of 60%, and the patient has reported no symptoms since the event.
There is limited evidence on treating coronary involvement in BD.1-2 Although antithrombotic therapy duration is debated, glucocorticoids and immunosuppressants are the cornerstone for treatment.2 Vasculitis should be considered in young patients with a coronary aneurysm. PCI should be reserved in the inactive disease phase because of the risk of stent/vessel mismatch, vessel overstretching, and coronary dissection risk, unless in cases of high-risk features such as hemodynamic instability.2-3
Affiliations and Disclosures
Deniz Mutlu, MD1; Zafer Akman, MD2; Mehmet Semih Belpinar, MD3; Cezar A. Iliescu, MD, FACC, FSCAI4; Konstantinos Marmagkiolis, MD, FACC, FSCAI4,5; Mehmet Cilingiroglu, MD, FACC, FSCAI, FAHA, FESC, FACP4
From the 1Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, Minnesota; 2Yale University, New Haven, Connecticut; 3Kartal Kosuyolu High Training and Research Hospital, Istanbul, Turkey; 4University of Texas, MD Anderson Cancer Center, Houston, Texas; 5Tampa General Hospital, University of South Florida, Tampa, Florida.
Disclosures: The authors report no financial relationships or conflicts of interest regarding the content herein.
Consent statement: The authors confirm that patient consent is not applicable to this article. This is a retrospective case report using de-identified data; therefore, the institutional review board did not require consent from the patient.
Address for correspondence: Mehmet Cilingiroglu, MD, FSCAI, FACC, FESC, FAHA, University of Texas in Houston, MD Anderson Cancer Center, Houston, TX 77030, USA. Email: cilingiroglumehmet@gmail.com
References
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2. Bettiol A, Alibaz-Oner F, Direskeneli H, et al. Vascular Behçet syndrome: from pathogenesis to treatment. Nat Rev Rheumatol. 2023;19(2):111-126. doi:10.1038/s41584-022-00880-7
3. Abou Sherif S, Ozden Tok O, Taşköylü Ö, Goktekin O, Kilic ID. Coronary artery aneurysms: a review of the epidemiology, pathophysiology, diagnosis, and treatment. Front Cardiovasc Med. 2017;4:24. doi:10.3389/fcvm.2017.00024
