An unusual case of early myocardial infarction: paradoxical coronary embolism in patient with patent foramen ovale

Case Report: A 40 years old male patient was admitted to our CCU after acute onset of chest pain. The diagnostic EKG showed a sinus rhythm with a transient ST-segmentelevation in the inferior leads. Markers of cardiac injury were elevated (Troponin-I 9.6 ng/mL at peak). Patient underwent emergency coronary angiogram with evidence of complete, embolic occlusion of left anterior descending artery at the level of the apical recurrent branch. Given the small dimension of this very distal vessel, no percutaneous intervention was performed. Echocardiography showed a mild left ventricular systolic dysfunction (EF 45%) with inferior wall and apical akinesia. The patient was completely free from cardiovascular risk factors. He had a history of migraine and a minor stroke 30 years before with a brain CT-scan showing multiple ischemic areas. In order to investigate the possible etiology of the thrombotic event, we searched for a ovale foramen patency and thrombophilia. A contrast echocardiography confirmed the clinical suspicion of patent foramen ovale (PFO) with massive right to left shunt, while screening for thrombophilia was negative. Initially the patient was pharmacologically treated with a triple antithrombotic therapy (aspirin, clopidogrel and enoxaparin), then he underwent percutaneous closure of PFO with Amplatzer® septal occluder 27mm. Procedure was uneventful and the patient completely recovered. Dual antiplatelet theraphy was prolonged for 1 year after the index event. At 12 months of follow-up the patient was completely asymptomatic with contrast echocardiography showing no evidence of residual interatrial shunt. Discussion: Paradoxical coronary artery embolism is a rare but under-diagnosed cause of acute myocardial infarction and requires a high level of clinical suspicion to make an early diagnosis. PFO is a common congenital cardiac anomaly that has been shown to be an independent risk factor for cerebrovascular events, particularly among young adults with cryptogenic stroke. Embolic events occurring through the PFO can also affect other vascular districts, including coronary and peripheral arteries. Here we report a case of an acute myocardial infarction in a young man with a PFO. In our opinion this case highlights the importance of searching for the presence of a PFO in young patients with thrombotic coronary events.