Myocardial Infarction with Non Obstructive Coronary Atherosclerosis: A Rare Case

Abstract

Background: Myocardial Infarction with Non-Obstructive Coronary Arteries (MINOCA) is a syndrome with different causes, characterized by clinical evidence of myocardial infarction with normal or near-normal coronary arteries on angiography. Cardiovascular Magnetic Resonance imaging (CMR) is increasingly used in cardiology to complement the diagnostic work-up of patients with cardiovascular disease, including MINOCA. The case below illustrates the clinical role of CMR in patients with acute coronary syndrome and unobstructed coronary arteries, and its usefulness in reaching the final diagnosis. It also highlights the possible link between aortic bioprosthetic valves as a source of emboli leading to MINOCA.

 Case Presentation: Here we describe an interesting case of a 29 year old male known to have bioprosthetic aortic valve replacement who presented with chest pain suggestive of the acute coronary syndrome, with rising troponin levels but having a normal coronary angiography and a cardiac magnetic resonance imaging showing revealed hypokinesia and thinning of the basal to mid lateral wall of the left ventricle and edema of the basal to mid lateral wall. Given the Cardiac MRI findings the patient was diagnosed with MINOCA. He was treated with aspirin bisoprolol and atorvastatin in the hospital setting.

 Discussion: CMR plays an important role in the confirmation of MINOCA. It provides a unique opportunity to noninvasively characterize heart tissue. Consequently, it has a crucial role to complement the diagnostic workup of patients with cardiovascular disease and to screen for the underlying cause. This case posed a challenge to establish an underlying cause for the myocardial infarction.

 Conclusion: This case illustrates the increasing clinical role of cardiac magnetic resonance imaging in modern cardiology and its ability to detect a final diagnosis in patients with MINOCA and also raise the possibility of recurrent embolic phenomena to the epicardial vessels from bioprosthetic valves, which might be challenging to prove.