Unmasking coronary embolism: rare non-atherosclerotic causes of acute coronary syndrome in the young: case series.

BACKGROUND: Coronary embolism is an uncommon, non-atherosclerotic cause of acute coronary syndrome (ACS) and is frequently under-recognized. We describe three rare presentations of coronary embolism causing ACS in young patients. CASES SUMMARY: Case 1: A 23-year-old male developed inferior wall myocardial infarction due to septic coronary embolism complicated by basal inferior submitral aneurysm and mitral valve infective endocarditis with anterior mitral leaflet perforation. He underwent mitral valve replacement and aneurysm repair. Case 2: A 35-year-old male presented with acute inferior wall myocardial infarction secondary to tumour embolism from left atrial myxoma and underwent mass excision, mitral annuloplasty, and coronary artery bypass grafting. Case 3: A 38-year-old female with non-ST elevation myocardial infarction and severe mitral stenosis demonstrated probable coronary embolism without atrial fibrillation or left atrial appendage thrombus and was managed with anticoagulation and planned percutaneous transmitral commissurotomy. DISCUSSION: The aetiology and source for coronary embolism in majority of the non-atherosclerotic ACS patients become clear from past symptoms in history and cardiovascular imaging. The treatment in most cases of coronary embolism depends on the site of obstruction, i.e. distal branch vessel vs. proximal vessel obstruction and also the nature of suspected embolic material. Aspiration thrombectomy and anticoagulation remains the mainstay in majority of thromboembolic lesions, whereas non-thrombotic lesions need to be managed on an individualized approach. CONCLUSION: Coronary embolism should be considered among the differential diagnoses of myocardial infarction with non-obstructive coronary arteries and ACS in young patients without significant atherosclerotic disease, particularly when an embolic substrate is identifiable.