Unique case of ST-segment-elevation myocardial infarction related to paradoxical embolization and simultaneous pulmonary embolization: clinical considerations on indications for patent foramen ovale closure in no-guidelines land

Acute Myocardial Infarction in the Setting of Pulmonary Hypertension due to a Patent Foramen Ovale and Paradoxical Embolism

A 67-year-old woman with pulmonary hypertension (PH) presented with a 1-day history of worsening shortness of breath and pleuritic chest pain and was found to have a troponin T level of 3755 ng/L (ref. range 0-19 ng/L). An initial diagnostic workup in the emergency department (ED) led to an urgent left heart catheterization which revealed a 90% occlusive right coronary artery blood clot, even though a recent heart catheterization less than a month prior was completely unremarkable. Further workup led to the discovery of a patent foramen ovale (PFO) and an aneurysmal interatrial septum, suggesting the presence of a paradoxical embolism. While typically asymptomatic, a PFO is an important clinical entity that can lead to irreversible cardiac damage. Suspicion should be high for this finding in the case of an acute myocardial infarction (MI) with no clear cause, especially in a patient with elevated right heart pressures.

Concomitant acute pulmonary embolism, myocardial infarction and ischemic stroke due to paradoxical embolism from a patent foramen ovale: a case report

A patent foramen ovale (PFO) is a cause of paradoxical embolism. Although most patients with a PFO are asymptomatic, various clinical manifestations may be associated with PFO. The most important is a cryptogenic stroke. Concomitant acute pulmonary embolism (APE), acute myocardial infarction (AMI) and acute ischemic stroke (AIS) due to paradoxical embolism from a PFO are extremely rare. We describe a 77-year-old woman with a past medical history of hypertension who was transferred due to a sudden onset of dyspnea followed by cardiopulmonary arrest. Based on the patient’s medical history, transthoracic and transesophageal echocardiography, coronary angiography, and a whole-body contrasted computed tomography, we diagnosed concomitant APE, AMI and AIS caused by a paradoxical embolism from a PFO. Appropriate knowledge of the pathophysiology of this rare critical illness is important for prompt diagnosis and treatment.

Wide-ranging clinical spectrum of paradoxical embolism

The purpose of this review is to raise the index of suspicion for paradoxical embolism among generalists. The review is based solely on anecdotal reports compiled from EMBASE, MEDLINE, Googlescholar and Pubmed. Search terms were 'paradoxical embolism', 'pulmonary embolism' and 'pulmonary arteriovenous malformations'. What emerged was that right-to-left paradoxical embolism could occur with or without concurrent pulmonary embolism, and also with and without proof of the presence of an 'embolus-in-transit'. Potential sites of single or multiple systemic involvement included the central nervous system, the coronary circulation, renal arterial circulation, splenic circulation, the mesenteric circulation and the limbs. In many cases, the deep veins of the lower limbs were the source of thromboembolism. In other cases, thrombi originated from an atrial septal aneurysm, from a central venous line, from a haemodialysis-related arterio-venous shunt, from a popliteal vein aneurysm, internal jugular vein, superior vena cava, from a pulmonary arteriovenous malformation, from tricuspid valve endocarditis (with and without pulmonary embolism) and from the right atrium, respectively. Stroke was by far the commonest systemic manifestation of paradoxical embolism. Some strokes were attributable to pulmonary arteriovenous malformations with or without coexistence of intracardiac shunts. Clinicians should have a high index of suspicion for paradoxical embolism because of its time-sensitive dimension when it occurs in the context of involvement of the intracranial circulation, coronary circulation, mesenteric circulation, and peripheral limb circulation.

Thrombus straddling a patent foramen ovale and pulmonary embolism: A case report

BACKGROUND

Venous thromboembolism is a common vascular syndrome presenting as deep vein thrombosis and/or pulmonary embolism. Thrombus has the possibility of migrating into the left circulation via patent foramen ovale in certain extreme circumstances. Thrombus straddling a patent foramen ovale is a direct evidence of this scenario. However, the confirmed cases of thrombus in transit are still rare.

CASE SUMMARY

A 32-year-old man suffered from recurrent syncope and intermittent dyspnea for 1 wk. Transthoracic echocardiography confirmed a thrombus straddling the patent foramen ovale, and thrombi were also found in the bilateral pulmonary artery by computed tomography. The man underwent inferior vena cava filter placement and thrombolysis with alteplase. Echocardiography showed the absence of thrombi in both the right atrium and left atrium 2 d after hospitalization. The man was discharged to home on warfarin without any complications 2 wk later.

CONCLUSION

Scrutinizing intracardiac thrombi provides measurable value in pulmonary embolism as closure of patent foramen ovale may be considered in certain patients. Early intervention plays a critical role in thrombus straddling a patent foramen ovale. A sedentary lifestyle may predispose young adults to thromboembolism, even if there are no other risk factors.

Acute Pulmonary Embolism: Focus on the Clinical Picture

Acute pulmonary embolism (APE) is characterized by numerous clinical manifestations which are the result of a complex interplay between different organs; the symptoms are therefore various and part of a complex clinical picture. For this reason, it may not be easy to make an immediate diagnosis. This is a comprehensive review of the literature on all the various clinical pictures in order to help physicians to promptly recognize this clinical condition, remembering that our leading role as cardiologists depends on and is influenced by our knowledge and working methods.

Concomitant pulmonary embolism and myocardial infarction due to paradoxical embolism across a patent foramen ovale: a case report

Concomitant acute myocardial infarction (MI) and pulmonary embolism (PE) is exceedingly rare. However, establishing the diagnosis early is essential, since delay in treating the patient may lead to a potential fatal outcome. Right ventricular (RV) infarction in the setting of inferior ST-segment elevation MI (STEMI), coupled with acute massive PE confers particular risk due acute RV failure and low cardiac output, threatening survival. We report a rare case of concomitant PE and inferior STEMI in a 43-year-old woman with a history of acute chest pain. She was haemodynamically compromised, with Type I respiratory failure but lack of signs of heart failure. Early recognition of dual pathologies prompted administration of thrombolytic therapy and simultaneous right coronary artery thrombectomy to treat PE and STEMI. Prompt clinical diagnosis and delivery of targeted therapies adapted for the specific clinical presentation may have averted fatal outcome.

Ischemic heart disease in children and young adults with congenital heart disease in Sweden

BACKGROUND

An increasing proportion of congenital heart disease (CoHD) patients survive to an age associated with increased risk of developing ischemic heart disease (IHD). The aim was to investigate the risk of developing IHD among children and young adults with CoHD.

METHODS

Using the Swedish National Patient Register, we created a cohort of all CoHD patients born between January 1970 and December 1993. Ten controls matched for age, sex, county were randomly selected from the general population for each patient (n=219,816). Patients and controls were followed from birth until first IHD event, death, or December 31, 2011.

RESULTS

We identified 21,982 patients with CoHD (51.6% men), mean follow-up was 26.4 (21.2-33.9) years. CoHD patients had 16.5 times higher risk of being hospitalized with or dying from IHD compared to controls (95% CI: 13.7-19.9), p<0.0001. Patients with conotruncal defects and severe nonconotruncal defects, had the highest IHD incidence rate (71.1 and 56.3 cases per 100,000 person-years, respectively, compared to 2.9 and 2.3 in controls). Hypertension and diabetes were less common among CoHD patients with IHD than among controls with IHD (hypertension 9.7% vs 19.7%, diabetes 1.8% vs 7.7% in CoHD patients and controls). Patients with aortic coarctation did not have a specific increase in the risk of developing IHD or acute myocardial infarction.

CONCLUSIONS

In this large case-control cohort study, the relative risk of developing IHD was markedly higher in CoHD patients than in controls. However, the absolute risk was low in both groups.