Primary Angioplasty for Cardiac Allograft Vasculopathy Presenting as ST-Elevation Acute Myocardial Infarction during Endomyocardial Biopsy

Cardiac allograft vasculopathy is still a major issue, with significative mortality in heart transplant patients, and the best therapeutic options are not yet established. The progressively higher survival rates after transplantation have made it a major concern. This is a case report about a patient who underwent cardiac transplantation due to chagasic cardiomiopathy. During an endomyocardial biopsy more than 2 years after the transplant, the patient arrested in ventricular fibrillation, with ST-elevation in anterior leads after defibrillation. The angiography showed total occlusion of proximal left anterior descending artery, promptly treated with primary angioplasty, with excellent angiographic and clinical results. 1. Introduction The cardiac allograft vasculopathy (CAV) is a major cause of morbidity and mortality in patients undergoing cardiac transplantation, and, as the survival rates increase, there has been a growing concern about its clinical management. Sudden death and graft ventricular dysfunction are some of the main manifestations, with cases presenting as acute coronary syndromes reported in the literature. This is a report of a patient after cardiac transplant due to Chagas disease that developed cardiac arrest immediately after endomyocardial biopsy, with postdefibrillation electrocardiogram suggestive of ST-elevation acute myocardial infarction in the anterior wall, successfully treated with primary angioplasty. 2. Case Report Patient, DMS, male, 40 years, had undergone heart transplantation 2 years and 3 months ago due to Chagas cardiomyopathy. The donor was a young male, without any known cardiovascular risk factors. The patient remained stable until a month ago, when he was admitted to the hospital with moderate dyspnea. Late allograft rejection was diagnosed, histopathologically graded as 3A by endomyocardial biopsy. The patient was subjected to intravenous pulse therapy with corticosteroids and was discharged asymptomatic, on tacrolimus 6？mg/d, mycophenolate sodium 1440？mg/d, prednisone 40？mg/d, simvastatin 40？mg/d, and benzimidazole 300？mg/d. Echocardiogram performed during hospitalization showed normal left ventricular (LV) function, with left ventricle ejection fraction (LVEF) = 80%. After discharge the patient was referred for elective endomyocardial biopsy. During the procedure, immediately after removal of the third fragment without complications, he arrested due to ventricular fibrillation and was immediately defibrillated. The electrocardiogram (EKG) after the arrest showed ST-segment elevation up to 5？mm in V1 to V6, DI,