Repeated Coronary Artery Thrombosis after mRNA-1273 COVID-19 Vaccination

INTRODUCTION

COVID-19 vaccination has been launched worldwide since December 2020. The authority of Taiwan started the vaccination campaign in March 2021. Currently, ChAdOx1 nCoV-19 and mRNA-1273 vaccines are available in Taiwan. Little data exist about the thromboembolic event after the vaccination. One of the most known severe adverse reactions after vaccination is vaccine-induced thrombosis and thrombocytopenia (VITT), which have been mainly reported as venous thromboembolic events after the ChAdOx1 nCoV-19 vaccine.¹ According to recent studies, the presence of antiplatelet factor 4 antibody is one of the causes of VITT.² The main adverse cardiovascular event of mRNA-1273 vaccine is myocarditis.³ Limited data exist about the mRNA-1273 vaccine-related VITT.^4,5 We are reporting a case of a patient with acute myocardial infarction with onset less than 24 hours after the first dose of mRNA-1273 vaccine. Subacute in-stent thrombosis happened days after percutaneous coronary intervention. VITT was suspected because of the presence of antiplatelet factors 4 antibody in the serum of the patient. We are reporting this case of patient to make clinicians aware the possibility of mRNA-1273 related VITT. However, this report should in no way diminish enthusiasm about vaccination.

CASE

This 63-year-old male patient had histories of hypertension and type 2 diabetes mellitus with regular medical control. He felt chest pain over left side chest wall within 24 hours after receiving the first dose of mRNA-1273 vaccine. The pain radiated to left shoulder which was the injection site with soreness. The pain was improved slightly but he still needed to take analgesic drugs. He visited emergency department four days later. The polymerase chain reaction test of his nasopharyngeal aspirates was negative for SARS-CoV-2. He developed hemodynamic collapse suddenly at the emergency department. His electrocardiogram (ECG) showed the finding of ventricular fibrillation. After cardiopulmonary resuscitation and extra-corporeal membrane oxygenation (ECMO) implantation, he received coronary catheterization immediately. The coronary angiography showed total occlusion with thrombus formation from the proximal part of left anterior descending artery (LAD). The other coronary arteries were patent (Figure 1A). Therefore, he received percutaneous coronary intervention for the culprit lesion. Due to the thrombus formation, he received a Terumo 6 french Eliminate aspiration catheter for the thrombus aspiration, and some white thrombus was aspirated. Predilatation for the lesion was done with a 2.0 mm × 15 mm semicompliance balloon. He received the placement of drug eluting stent (Biosensors 3.0 mm × 29 mm Biomatrix Alpha drug-eluting stent) at the proximal part of the LAD. The final angiogram showed an optimal result with TIMI III flow (Figure 1B). The patient was then transferred to intensive care unit. Echocardiography showed impaired left ventricular ejection fraction (44%) with anterior wall hypokinesis. ECMO was removed on the third day of admission. But the patient developed another hypotension with oxygen desaturation on the seventh day. The ECG finding showed sinus tachycardia with newly onset ST elevation in V1-V3 (Figure 2). Emergency coronary catheterization showed total occlusion from the proximal part of LAD (Figure 1C). We suspected the diagnosis of subacute in-stent thrombosis. He regained coronary artery flow after repeating dilatation with non-compliance balloon under intravascular ultrasonographic guide. Because he had repeated thromboembolic events after the COVID-19 vaccination, we checked his serum titer of antiplatelet factor 4 antibody. The result was positive (156.31 ng/ml, optical density value 1.285; reference: positive if > 50 ng/ml or optical density value > 0.4). In addition, he also had thrombocytopenia (105 × 10⁹/L, normal range 130-400 × 10⁹/L). According to the diagnosis criteria of World Health Organization (WHO), VITT was diagnosed (1 major criterion and 2 minor criteria, level 1).⁶ He received intensive care and triple therapy with aspirin, as well as clopidogrel and rivaroxaban. But he expired due to profound cardiogenic shock and acute renal failure on the fourteenth day of admission.

Figure 1.

(A) Thrombosis in ostium of left anterior descending artery with total occlusion. (B) Post-stenting angiography of left anterior descending artery. (C) In-stent thrombosis of left anterior descending artery.

Figure 2.

Sinus tachycardia with bigeminal atrial premature complexes, right bundle branch block, and ST elevation inV1 to V4.

DISCUSSION

To prevent infection of COVID-19, several vaccines have been widely available to the public. Thrombosis with thrombocytopenia has been reported after vaccination against COVID-19 with two vaccines based on recombinant adenovirus vectors — the ChAdOx1 vaccine from AstraZeneca¹ and the Ad26.COV2.S vaccine from Johnson & Johnson/Janssen,^7,8 and it is known as vaccine-induced thrombosis with thrombocytopenia (VITT). The WHO has established the diagnosis criteria for VITT.⁶ Until now, only few reports exist for having VITT after a COVID-19 vaccine based on messenger RNA (mRNA) technology.^4,5

Based on this case report, our patient developed thrombosis and thrombocytopenia within days after the vaccination. Although the distribution of the thrombosis is mainly at coronary arteries and the severity of thrombocytopenia was mild, which met the minor criteria of VITT. But in our patient the occurrence of subacute in-stent thrombosis and the presence of anti-platelet factor 4 antibodies on enzyme-linked immunosorbent assay strengthened the possibility of VITT. This case report is limited because of failure of checking D-dimer titer initially and inability to rule out atypical heparin-induced thrombocytopenia (HIT) or HIT with previous heparin administration.

LEARNING POINT

As the campaign of COVID-19 vaccination becomes popular worldwide recently. More safety data will be available on the potential side effect of these vaccines. We suggested that this case report may raise awareness of the healthcare providers about the possible correlation between myocardial ischemia after COVID-19 vaccination. But this rare side effects reported in this care report should not prevent persons from receiving these vaccines because of out-weighted benefits. More studies should be launched and evaluated carefully before commenting on the coincidence of VITT and mRNA base vaccine.

DECLARATION OF CONFLICT OF INTEREST

All authors declare no conflicts of interest.