Introduction: Acute embolism from artificial aortic valve to the coronary arteries resulting in acute myocardial infarction is an uncommon occurrence. There are cases reported in acute setting after mechanical aortic valve replacement, although embolization in properly anticoagulated patients, years after aortic valve replacement is rare. (1, 2)

Case report: We report the case of a 64-year-old man who underwent an aortic valve replacement six years earlier and presented to the emergency department with myocardial infarction without ST elevation. He was adequately anticoagulated with warfarin. Transthoracic echocardiography showed normal motion of bileaflet artificial aortic valve, without visualized thrombi or detected abnormally pressure gradient. 12-lead ECG showed ST depression in inferior and lateral leads, while urgent coronary angiography revealed subtotal atherothrombotic lesion of right coronary artery, but without significant coronary artery disease of left coronary artery. Percutaneous coronary intervention of right coronary artery was performed with implantation of one stent. Repeated ECG showed isoelectric level of ST segment. After four days of hospitalization sudden onset of prodromal chest pain occurred. ECG showed deep ST depression in anterolateral precordial leads. Coronary angiography was proposed to the patient, but the patient denied the procedure. One day later, after refractory cardiac arrest, patient died. Autopsy revealed thrombotic occlusion of left anterior descending artery with recent myocardial necrosis of left ventricle anterior wall and few microemboli of the aortic mechanical valve.

Discussion: Embolic myocardial infarction is underdiagnosed and it is important to diagnose the source of embolism and treat the cause. Despite the patient was adequately anticoagulated, it is considered that even adequate anticoagulation therapy does not eliminate the risk of thromboembolism. Also, favorable in this patient was bileaflet type of valve, which is less thrombogenic. Review of related literature did not show similar cases occurring in relatively short period of time, resulting in recurrent myocardial infarction with emboli of both left and right coronary artery.