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DOI: 10.1055/s-0041-1739806
A case of microvascular myocardial infarction in a postpartum patient with antiphospholipid syndrome
Introduction Antiphospholipid syndrome (APS) occurs predominantly in reproductive-age women. Pregnancies in women with APS are characterized by an increased rate of maternal and obstetric complications. We describe a patient with triple-positive APS and a history of recurrent thromboembolic events prior to pregnancy who, after an uneventful pregnancy and birth, developed acute microvascular myocardial infarction attributable to her autoimmune disease six days postpartum.
Case Report The 31-year old G1 P0 with triple-positive APS diagnosed after deep vein thrombosis and pulmonary embolism in 2007 had a stable course of disease in the years preceding the pregnancy. She experienced an uneventful pregnancy, with normal fetal development.g/d). Induction of labor was performed at gestational age 37+0 for a decreasing platelet count (from 120 G/l to 87 G/l). Birth and Her medication included acetylsalicylic acid (100 mg/d) and low-molecular-weight heparin (LMWH, Enoxaparin 60mpostpartum course were uneventful (female, 2356 g, 8th percentile, APGAR 8/9/10, umbilical artery pH 7,21). LMWH was continued postpartum (60mg/d). On the sixth day postpartum she presented with acute, severe chest pain. The electrocardiogram and initial transthoracic echocardiography did not reveal any abnormalities. Based on an exorbitant Troponin T level (733 ng/l), pulmonary CT-angiography and cardiac catheterization was performed, showing no evidence of pulmonary or coronary thromboembolism; however, reduced LV-function (ejection fraction (EF) of 40%) with global hypokinesia had developed. The cardio-MRT revealed Gadolinium-enhancement in the arterioles of both coronary arteries suspecting microvascular infarction (see Figure). Her cardiac function deteriorated further (lowest EF 35%). Therapeutic anticoagulation and standard congestive heart failure therapy was commenced. She was discharged after 18 days. One month later, LV-function had recovered (EF 50%) with ongoing medication.
Discussion Cardiac involvement in APS is common, consisting of valvular or coronary artery disease, myocardial dysfunction, intracardiac thrombosis, and pulmonary hypertension. We excluded other causes of acute myocardial dysfunction and catastrophic APS and therefore assume that our case of microvascular myocardial infarction of the coronary arterioles is another cardiac manifestation of APS. Its occurrence despite anticoagulation in our young patient without cardiovascular risk factors is remarkable and highlights the necessity of high awareness and close interdisciplinary management to reduce maternal morbidity and mortality for this severe condition.
Leg.: MRT images in short axis orientation. Post-contrast steady-state free precession (SSFP, A and B) showing, exemplarily, subendocardial sparing of contrast enhancement (white arrows). Late gadolinium enhancement (LGE) images (C and D) demonstrating thin subendocardial myocardial infarctions (white arrows).


Publication History
Article published online:
26 November 2021
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