Acute coronary syndrome of paradoxical origin

Abstract

We describe a rare case of acute myocardial infarction secondary to paradoxical embolism complicating acute pulmonary embolism. A 44-year-old woman presented to the emergency department with chest pain. The physical examination was unremarkable except for oxygen saturation of 75%, and the electrocardiogram showed ST-segment elevation in the inferior leads. Urgent coronary angiography showed a distal occlusion of the right coronary artery and multiple thrombi were aspirated. Despite relief of chest pain and electrocardiogram normalization, her oxygen saturation remained low (90%) with high-flow oxygen by mask. The transthoracic echocardiogram showed a mass in the left atrium and dilatation of the right chambers, while the transesophageal echocardiogram showed a thrombus attached to the interatrial septum in the region of the foramen ovale. Color flow imaging was consistent with a patent foramen ovale. Thoracic computed tomography angiography documented thrombi in both branches of the pulmonary trunk. After five days on anticoagulation, the patient underwent surgical foramen ovale closure. © 2010 Sociedade Portuguesa de Cardiologia Published by Elsevier España, S.L. All rights reserved. PALAVRAS-CHAVEEmbolia paradoxal; Foramen ovale patente; Enfarte do miocárdio Síndrome coronária aguda de origem paradoxalResumo Descreve-se um caso raro de enfarte agudo do miocárdio por embolia paradoxal em contexto de tromboembolismo pulmonar agudo. Uma mulher de 44 anos recorreu à urgên-cia por dor torácica. A observação foi normal com exceção de saturação periférica de 75%. O electrocardiograma mostrou supradesnivelamento do segmento ST nas derivações inferiores. Realizou-se cateterismo urgente que mostrou coronária direita ocluída distalmente, tendo sido aspirados múltiplos trombos. Verificou-se alívio da dor e desaparecimento do supradesnivelamento de ST. No entanto, a saturação periférica mantinha-se baixa apesar de aporte com oxigénio. O ecocardiograma transtorácico mostrou massa auricular esquerda e dilatação das cavidades direitas. O ecocardiograma transesofágico revelou um trombo no septo interauricular, na região do foramen ovale. O estudo por Doppler-cor foi compatível com foramen ovale * Corresponding author. E-mail address: aritaf@gmail.com (A.R. Ferreira). patente. A angio-tomografia computorizada do tórax documentou trombos nos ramos principais da artéria pulmonar. Após cinco dias de anticoagulação a doente foi submetida a cirurgia cardíaca e o foramen ovale encerrado.

Congenital heart disease: types, pathophysiology, diagnosis, and treatment options

“…We found that most patients with paradoxical coronary embolism presented with ST‐elevation myocardial infarction rather than non‐ST‐elevation myocardial infarction, and the infarct territory involved mainly inferior or posterior left ventricular wall 53 . While previous studies revealed that most coronary emboli lodged in the LAD artery, 54 we found that in most cases of presumed PFO‐mediated coronary paradoxical embolism, the emboli were located in a distal or branch segment of the right coronary artery (RCA), followed by the left circumflex artery (LCX), and least in the LAD 55–57 . For example, Ghafoor et al 55 .…”

“…53 While previous studies revealed that most coronary emboli lodged in the LAD artery, 54 we found that in most cases of presumed PFO-mediated coronary paradoxical embolism, the emboli were located in a distal or branch segment of the right coronary artery (RCA), followed by the left circumflex artery (LCX), and least in the LAD. [55][56][57] For example, Ghafoor et al 55 described a 33-year-old woman with acute inferior myocardial infarction presenting with occlusion of the distal RCA on coronary angiography due to coronary paradoxical embolism secondary to PFO. In another study by Wilson et al, 58 a 28-year-old man with AMI and coronary paradoxical embolism in the branch of the LCX secondary to PFO was reported.…”