Acute Myocardial Infarction Due to Nonbacterial Thrombotic Endocarditis in Advanced Intrahepatic Cholangiocarcinoma: A Case Report

BACKGROUND Although coronary embolism associated with malignancy has been previously reported, cases of acute myocardial infarction (AMI) due to coronary embolism from non-cardiac tumors are rare, and progression to cardiac rupture is exceedingly uncommon. We report a case of AMI that progressed to cardiac rupture, caused by nonbacterial thrombotic endocarditis (NBTE) stemming from intrahepatic cholangiocarcinoma. CASE REPORT An 81-year-old woman presented with loss of appetite, asthenia, and weight loss. Imaging revealed multiple liver tumors and suspected pulmonary metastases, and a liver biopsy was scheduled. However, she died suddenly 3 days later. Autopsy revealed intrahepatic cholangiocarcinoma, predominantly affecting the right hepatic lobe, with metastases to the lungs and other organs. Importantly, it also revealed cardiac tamponade due to left ventricular rupture. Histopathological examination showed thrombotic occlusion of both epicardial and microvascular branches in the distal left anterior descending artery, with associated myocardial necrosis. Although a small number of tumor cells were present in the coronary vasculature, there was no evidence of direct vascular obstruction due to tumor embolism. In contrast, the presence of aseptic vegetations on multiple valves was consistent with NBTE, suggesting that thromboembolism resulting from NBTE was the main cause of severe AMI. CONCLUSIONS This case illustrates a rare instance of severe AMI with cardiac rupture caused by NBTE-associated coronary thromboembolism secondary to advanced intrahepatic cholangiocarcinoma. NBTE should be considered a potential cause of coronary embolism, particularly in patients with advanced malignancies presenting with unexplained AMI.