Pharmacology > Cases

Sudden Cardiac Death After Drug-Eluting Stent Implantation and Interruption of Antiplatelet Therapy

- Operator: Sang-Sig Cheong, MD

Past History

A fifty-nine year old man was referred to Asan Medical Center for elective lung cancer operation. He had previous history of myocardial infarction (MI) in inferior wall 13 years ago and received conservative medical management without thrombolysis or percutaneous coronary intervention. His coronary risk factor was smoking. Two-month ago, he was admitted to other hospital with unstable angina. Baseline ECG showed pathologic Q wave in inferior leads and left ventricular hypertrophy (Figure 1). Echocardiography revealed a regional wall motion abnormality in right coronary artery (RCA) territory with preserved left ventricular (LV) systolic function (EF = 60%).

Stenting procedure and clinical course

Baseline coronary angiogram showed total occlusion at proximal RCA with bridging collaterals and significant diffuse narrowing at proximal left anterior descending artery (LAD) (Figure 2, Figure 3, Figure 4). After engaging of a 6F Judkin 3.5 guiding catheter via trans-radial approach, a 0.014 inch Ninato wire was introduced into the LAD. After pre-dilatation with a Maverick 3.0 mm x 10 mm up to 3.09 (12 atm), proximal LAD was stented with a 3.0 mm x 33 mm Cypher stent at 13 atm (Figure 5). Post-stenting balloon dilatation was performed with a Maverick 3.0 mm x 10 mm up to 3.23. Final angiogram showed a good result (Figure 6, Figure 7). Concomitant work-up for lung mass in left upper lobe (Figure 8) showed a squamous cell carcinoma in pathologic examination and T2/3N2M0 in staging.

After stenting, he was referred to Asan Medical Center for the treatment of lung cancer. He underwent a 3 week course of pre-operative neo-adjuvant chemotherapy and then was scheduled for curative operation. For elective operation, aspirin and clopidogrel were discontinued 1 week before surgery of lung cancer (57 days after stenting). On the morning of surgery (64 days after stenting), the patient suddenly present with severe chest pain. In an instant, bradycardia and hypotensive shock developed. Twelve-lead ECG revealed an undetermined idio-ventricular rhythm (Figure 9). Despite a prompt cardiac resuscitation, he finally expired.
The cause of sudden cardiac death in this patient was assumed as clinical late stent thrombosis.

Ohlmann2006-01-13
Several comments: - first there was no real proof of ischemia related to the LAD lesion, this patient maybe didn't need any revacularisation - second: in such a case, if ischemia make no doubt, it seem to me that revascularization by surgery (CABG) is more adapted since it doesn't need any antiplattelet therapy and carcinologic surgery may be done as soon as possible (i.e: one week after CABG), without wasting 1 to 6 month on plavix therapy. Additionnaly if stenting is the only possible approach, I would suggest to use bare metal stent to shorten the duration of antiplattelett therapy - third; the risk of stent thrombosis is probably higher in patients with other pathologic condition such as neoplasm which are often associated per se with a systemic inflammatory response (high CRP, high fibrinogen). This point reinfore the indication of CABG in such patients. Patrick Ohlmann, MD Strasbourg France
Goran Olivecrona2006-01-14
I agree with Dr Ohlman. CABG would be my first choice which would enable lung surgery within a few weeks without the risk of either subacute stent thrombosis or added bleeding risk. If The Cardiac Surgeons would have declined the patient then I would defenitely have opted for the BMS and schedueled surgery for 30 days after stentimplanataion. I would have maintained the patient only on aspirin during surgery then. Gran Olivecrona, Lund University, Sweden
J Yoon2006-01-15
I agree with previous comments. but, things we have to think are. It might be hard to refuse to treat his heart problem before his cancer treatment. He needed lobectomy or something, his cardiologist should have improved his cardiopulmonary condition before his surgery. Second, As a physician in charge,It is difficult to put him into two major surgery with no significant CABG indication like chest pain & DM then. Third, stent thrombosis is rare and we still don't have good anticoagulate indication for thromogenic patient. I would have followed up his conditon more than a year with anticoagulation, or have done echocardiography or coronary angiogram before his surgery. Juneyoung Yoon, South Korea
Young-Hak Kim2006-01-17
Actually, this was the first case of DES thrombosis before surgery that we have experienced. To tell the truth, as an interventionist, it was not always easy to decide DES vs. BMS vs. surgery. However, from this case, we agreed that BMS would be the first option before major surgery.
I would have done a nuclear stress test both to look for ischemia and risk stratification. Given the LVEF was normal, if the pt. was stable, I might just cover with beta-blocker and send for lung surgery. After all, if the Ca lung turned out to have metastatized and beyond curative resection, you may never have to imlant any stent. Even I need to stent, BMS would be my choice, beyond doubt!
Genshan Ma2006-01-22
I agree with previous comments. Anyway, I would like to do lung operation and CABG together for the patient if we found ischemia in the area of LAD. I got the same case a year ago. That patient was safely performed lung operation and CABG of two vessels. I also experienced a acute case with inferior infarction with a cypher stent implanted in CX. One month later, the patient was operated with a acute abodominal problem. Lukely, after two weeks discontinue antiplatelet therapy, the patient still had patent in Cx with the CAG examination. Ma Genshan, MD, Nanjing, China
Gim-Hooi Choo2006-01-22
Recently had a patient who developed late stent thrombosis about 9 months after Cypher implantation. You wouldn't believe it! He stopped all anti-platelet drugs 3 months after implantation and defaulted clinical follow-up and most cardiac medications. He remained well until he presented with recurrent acute anterior MI. Angiography revealed total stent occlusion. Significant thrombus burden was aspirated during primary PCI. My point is, it is really difficult to say when subacute/late stent thrombosis will occur. The trend of discussion suggests that BMS may predispose to less late thrombosis presumably from earlier endothelialisation, hence the choice of BMS over DES in this clinical scenario. However, available data has not demonstrated that DES is worse off when compared to BMS in terms of stent thrombosis. 9 months post-implantation, theoretically speaking, should be adequate for stent endothelialisation even for DES. The real problem I feel is whether we should place our patients on at least a single anti-platelet agent even on the day of surgery. I know that my surgical colleagues have traditionally been very apprehensive about anti-platelet agents. We need data to confirm the risk-benefit equation. Choo Gim Hooi MD, Malaysia
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