Paradoxical Coronary Embolism Research Articles

MYOCARDIAL INFARCTION SECONDARY TO PARADOXICAL EMBOLISM THROUGH PATENT FORAMEN OVALE : SURGICAL MANAGEMENT

Patent foramen ovale (PFO) is most often asymptomatic, but it can cause manifestations with varying degrees of severity. Paradoxical embolism, a condition associated with PFO, requires multidisciplinary management.Acute coronary syndrome (ACS) resulting from paradoxical coronary embolism should be suspected in all patients presenting with ACS who have normal coronary arteries on angiography, regardless of age. Our case illustrate a proven paradoxical coronary embolism through a PFO.

A "PARADOXICAL" MINOCA

Abstract Background The acronym MINOCA refers to myocardial infarction with normal or near–normal coronary arteries on invasive angiography. We report a case of MINOCA caused by paradoxical coronary embolism due to a right–to–left shunting through a patent fossa ovalis. Integrated multimodality imaging diagnostic work–up has been crucial for identifying the mechanism underlying MINOCA. Case Report A 48–year–old male was admitted to the Coronary Care Unit for sudden–onset oppressive chest pain lasting 1 hour, radiating to the left arm; no specific changes in ST–segment on a 12–lead ECG and elevated high–sensitive troponin I (peak value 1562 ng). Transthoracic echocardiography showed normal dimensions and function of the cardiac chambers and excluded valvular and pericardial diseases. Given the characteristics of the chest pain, we performed an urgent coronary angiography that showed normal epicardial coronary, including testing for epicardial coronary spasm and microvascular dysfunction. We also used Optical Coherence Tomography on LAD e RCA to rule out critical stenosis and sign of plaque instability. To investigate the etiology of myocardial damage the patient underwent a cardiac magnetic resonance (CMR) imaging that yielded the following findings: hypokinesis of the inferior–middle segment of the left ventricle associated myocardial edema and near transmural LGE. These features were consistent with a recent ischemic injury. Additionally, CMR showed an atrial septal aneurysm and a channel–like pattern of the interatrial septum, raising the suspicion of patent foramen ovale (PFO). The transesophageal echocardiography and transcranial Doppler with bubble test confirmed the presence of a PFO responsible for right–to–left shunting. Atrial fibrillation was excluded with ECG telemetry throughout the entire 7day hospitalization. Conclusions Based on the result of the overall clinical–instrumental evaluation, MINOCA caused by paradoxical coronary embolism due to a right–to–left shunting through a PFO was considered the most plausible diagnostic hypothesis. The patient underwent to interventional percutaneous closure of PFO and was discharged with no symptoms or complication at the follow–up.

Abstract 16233: Paradoxical Coronary Embolus Associated With Right Atrial Thrombus in Cardiac Amyloidosis

Introduction: This case highlights amyloidosis’ risk for intracardiac thrombosis with an atypical presentation of paradoxical coronary embolism due to right atrial thrombus. Clinical Presentation: An 87-year-old male with atrial fibrillation not on anticoagulation, HFrEF, severe mitral regurgitation, CKD3B, and recent medically managed NSTEMI, presented with shortness of breath. Labs showed elevated Troponin-T HS (174 ng/L) and proBNP (11,955 pg/mL). Echocardiogram revealed EF 25-30% with new lateral and anterior wall akinesis, concerning for NSTEMI I. Coronary catheterization revealed possible thrombus in the left circumflex artery (Figure 1A), but distal perfusion was intact. CT angiogram was negative for coronary artery dissection, providing clearance to initiate treatment with Eliquis. Intriguingly, cardiac MRI suggested intracardiac thrombus within the right atrial appendage and patent foramen ovale (Figure 1B), and possible amyloidosis from delayed gadolinium uptake. Despite negative serologic amyloid workup, pyrophosphate scan confirmed transthyretin amyloidosis. The patient was diuresed for decompensated heart failure but hypotension and acute-on-chronic kidney disease limited Guidelines-Directed Medical Therapy at discharge. Discussion: This case elucidates the importance of recognizing the thromboembolic risk in cardiac amyloidosis patients. Studies indicate up to 30% of cardiac amyloidosis patients have intracardiac thrombi, particularly those with primary amyloidosis subtype. Notably, no correlation exists between the CHA2DS2-VASc score and the presence of left atrial appendage thrombus in patients with cardiac amyloidosis and atrial fibrillation. Despite the left atrial appendage being twice more susceptible to thrombus formation, the right atrial appendage requires attention. Timely screening in high-risk patients could enable early thrombus detection, potentially improving prognosis.

Abstract 16294: A Case of Paradoxical Coronary Embolism in a Patient With Undiagnosed Malignancy

Introduction: Coronary embolism is a rare cause of acute myocardial infarction (AMI) in comparison with atherosclerotic plaque rupture. We present a case of an inferior ST elevation myocardial infarction caused by coronary embolism. The source was thought to be from the combination of deep vein thrombosis (DVT) and patent foramen ovale (PFO), accounting for a unique presentation and pathophysiology. Case: An 86-year-old female with a history of hypertension, non-small cell lung cancer status post resection with no residual disease, presented with a three-day history of epigastric discomfort, dyspnea on exertion and confusion. On presentation, she was afebrile with normal vital signs. Physical exam revealed epigastric pain on palpation. Initial labs were significant for high sensitivity troponin elevation to 9591 ng/L. ECG showed ST elevations in leads II, III, aVF. Coronary angiogram showed distal left anterior descending artery 71% stenosis and left posterior descending artery 99% stenosis. Given multiple distal locations concerning for coronary emboli, coronary angioplasty was done without stenting given no evidence of plaque rupture. After the angiogram, patient was found to have slurred speech and left sided facial droop. CT head showed multiple embolic infarcts. A transesophageal echocardiogram revealed a small PFO but no valvular vegetation/calcification or left atrial appendage thrombus. Lower extremity dopplers demonstrated lower extremity DVT. CT abdomen showed a pancreatic mass with hepatic metastasis, concerning for metastatic pancreatic adenocarcinoma. Patient was started on atorvastatin and aspirin only as AMI was due to a suspected embolic event. She received an IVC filter due to contraindication of anticoagulation in acute stroke and discharged to follow up with Oncology outpatient. Conclusions: In comparison to atherosclerotic plaque rupture, AMI as a result of an embolic coronary phenomena is rare. In fact, less than 1% of AMIs are caused by paradoxical embolism due to a PFO. There are many case reports about embolic AMI due to valvular vegetation or calcification. However, paradoxical coronary embolism due to PFO should be considered in patients with risk factors for a hypercoagulable state such as malignancy or DVT.

Myocardial Infarction Caused By An Enclosed Thrombus In A Patent Foramen Ovale

Paradoxical embolism in coronary artery is a rarely diagnosed clinical entity. In the majority of reported cases; the diagnostic of this pathology is « presumptive » based on certain criteria. It can be considered “proven” when the embolus is found lodged in the abnormal communication between the venous and arterial circulation; which is very rare. We herein report a case of myocardial infarction caused by a proven paradoxical coronary embolism through a patent foramen ovale. The authors highlight through this paper the contribution of echocardiography and particularly trans-esophageal echocardiography, especially if performed soon after presentation, for early diagnosis.

75-Year-Old Woman With Chest Pain and Shortness of Breath

75-Year-Old Woman With Chest Pain and Shortness of Breath

Paradoxical Coronary Embolism Causing Unstable Angina in an Octogenarian

Acute coronary syndrome resulting from paradoxical coronary embolism is a known and dreaded entity. It should be suspected in all patients who present with acute coronary syndrome with normal coronary arteries on angiography, irrespective of age. We report a case of an 80 year old male with unstable angina with atrial septal defect and 95% acute thrombotic occlusion of the right coronary artery with rest of the coronaries being normal on coronary angiography.

Epidemiology of Myocardial Infarction Caused by Presumed Paradoxical Embolism via a Patent Foramen Ovale.

Despite several negative prospective randomized trials on the efficacy of patent foramen ovale (PFO) occlusion, the discussion on indications is ongoing. Because the incidence of paradoxical coronary embolism through a PFO is unknown, we investigated the risk of paradoxical embolic myocardial infarction over a period of 13 years.Methods and Results:We conducted a retrospective and a prospective study. In the former, we searched the hospital database of a tertiary referral center for cases of acute myocardial infarction (AMI) during the past 10 years and screened them for possible paradoxical MIs. On this basis we started a prospective evaluation over 39 months in another tertiary referral center. All patients with AMI and normal coronary arteries were screened for PFO and if no other reason for the AMI could be found, the case was judged as presumed paradoxical embolism. In the retrospective analysis we found 22 cases (0.45%) of presumed paradoxical coronary artery embolism under 4,848 AMI. In the prospective study there were 11 presumed paradoxical coronary artery embolisms among 1,654 patients with AMI, representing an incidence of 0.67%. Our findings demonstrated that well below 1% of AMIs are caused by paradoxical embolism via an interatrial communication. Although this percentage appears low, it is not a negligible number of patients based on the huge number of MIs occurring in the industrialized world.

Undervalued Significance of Moderate Enzyme Elevation in Paradoxical Coronary Embolism Secondary to Deep Vein Thrombosis: Short Review

Myocardial infarctions (MI) are relatively common in people with deep vein thrombosis (DVT). In fact, the rate of myocardial infarction has been reported to be greater in adults with DVT as compared to those without DVT and recent studies have shown interest in quantifying the relationship with MI and DVT. However, cryptogenic nature of MI in these individuals is underestimated. Approximately one-fourth of the US populations are estimated to have a patent foramen ovale (PFO). Of note, since MI being the single largest cause of mortality, a large number of these patients have a PFO. The high percentage of myocardial infarction in patients with a PFO has not been addressed in the literature appropriately before and might have been overlooked because most of the patients with infarctions had an uncomplicated course and only moderate enzyme elevation.

Paradoxical coronary embolism as a cause of non-atherosclerotic acute coronary syndrome

Paradoxical coronary embolism as a cause of non-atherosclerotic acute coronary syndrome

Paradoxical coronary embolism and right to left shunting

Paradoxical coronary embolism and right to left shunting

121 High Diagnostic Yield in Patients Presenting with Acute Chest Pain, Positive Troponins but non-obstructive Coronaries by Cardiovascular Magnetic Resonance imaging with Conventional and Novel T1 Mapping Techniques

IntroductionUp to 10% of patients presenting with chest pain and elevated troponin levels demonstrate non-obstructive coronary arteries on angiography, posing a clinical challenge in diagnosis, prognosis and management. The final...

Just another acute myocardial infarction?

Introduction: Acute Myocardial Infarction in young people can be challenging to manage, as the underlying pathology can be different to the conventional atherosclerosis with plaque rupture. Case Description: A 36-year old man presented with sudden onset central chest pain and diaphoresis. Apart from smoking he did not have other risk factors for coronary disease. One week prior he underwent elective hip replacement and had been treated with prophylactic clexane to prevent venous thromboembolism. He was on no other regular prescribed or recreational medication. The EKG showed changes consistent with an inferoposterior STEMI. Emergency angiography revealed an occluded left circumflex with heavy thrombus burden. Following prolific thrombus aspiration TIMI 3 flow was restored, the patient became pain-free and the EKG started to normalize. The circumflex artery appeared smooth with no evidence of plaque rupture. An embolic cause was suspected and given that the patient was pain-free he was managed medically with aspirin, clopidogrel, beta-blockers and ace inhibitors and planned to re-study him in 48 hours. Bilateral lower limb ultrasound and CT pulmonary angiography did not reveal deep vein thrombosis or pulmonary embolus. Transthoracic bubble echocardiography revealed right to left shunting on valsava manoevre consistent with a PFO, also visualized on 3D transesophageal echocardiography. At coronary angiography 48 hours later, the circumflex coronary remained smooth with no evidence of further obstruction thus no stent insertion was needed. Histology of the thrombus confirmed a platelet thrombus forming on a foreign plastic material that was likely part of an intravenous cannula. It is likely that the plastic entered the circumflex at the time of orthopedic surgery and acted as nidus for thrombus formation. He has since underwent successful percutaneous closure of his PFO. Discussion: Paradoxical coronary embolism is a rare but recognized clinical entity. It requires a high index of suspicion for diagnosis and should always be considered in young patients presenting with acute myocardial infarction and no obvious coronary lesion as its correct identification can guide appropriate management and preclude inappropriate stent implantation. Implications to clinical practice: 1. Always beware of paradoxical embolism in young patients presenting with a STEMI, particularly if coronary arteries appear smooth. 2. Always be meticulous when inserting intravenous cannulae. Avoid needle re-insertion as this increases the risk of the cannula breaking off and embolizing with adverse outcomes as exemplified in our case.

Acute right ventricular failure caused by concomitant coronary and pulmonary embolism: successful treatment with endovascular coronary and pulmonary thrombectomy

Patent foramen ovale (PFO) is present in approximately 25% of the general population. PFO is characterized by intermittent shunting of blood from the right to the left atrium, especially in the context of increased right-sided filling pressures, with risk of paradoxical embolism. We describe a 69-year-old woman presenting with acute chest pain, severe dyspnoea, and acute inferolateral ST-segment elevation on the electrocardiogram. The patient was diagnosed with myocardial infarction and failure of the right cardiac ventricle, which was considered to be secondary to extensive pulmonary embolism leading to increased filling pressures and paradoxical coronary embolism. The patient underwent emergent percutaneous interventions with coronary thrombus extraction and pulmonary thrombus fragmentation and local thrombolysis. The patient was free of symptoms at follow up 6 months later and echocardiography showed substantially improved right ventricular function. We discuss issues related to the diagnosis, treatment, and secondary prevention for patients with concomitant pulmonary and coronary arterial thrombosis.

A rare case of paradoxical embolism causing myocardial infarction: Successfully aborted by aspiration alone

A 58-year-old male presented with severe substernal chest pain along with bilateral lower extremity pain. He was tachycardic, tachypneic, and hypoxic with tender right calf. Electrocardiogram showed ST elevation in anterior-lateral leads. Emergency coronary angiography revealed widely patent proximal left anterior descending (LAD) artery and total distal occlusion with an abrupt cut-off. The remaining coronary arteries did not have significant disease. An Export aspiration catheter was used and thrombus was aspirated from the LAD with return of TIMI flow grade 3 and normalization of the ST elevations. Doppler ultrasound revealed deep vein thrombosis; transthoracic echocardiogram using agitated saline echocontrast showed a patent foramen ovale. Nearly 5% of patients with ST elevation myocardial infarction do not have demonstrable atherosclerosis by coronary angiography; paradoxical coronary embolism is among the leading causes in such cases. Paradoxical embolism to the coronary tree is under diagnosed and its antemortem diagnosis is difficult. Information regarding appropriate management of myocardial infarction due to coronary embolism is scant. Aspiration of intracoronary thrombus provides good clinical results, avoiding clot fragmentation and balloon injury associated with angioplasty. We present a rare case of antemortem diagnosis of paradoxical embolism to the coronary artery successfully treated with aspiration alone.

Embolia aérea durante cesárea electiva y atonía uterina por feto macrosómico

We report the case of a paradoxical air embolism during a scheduled cesarean section for fetal macrosomia (7.010 kg) in a 38-year-old woman with a history of gestational diabetes and preeclampsia. Spinal anesthesia was satisfactory and well tolerated. After approximately 30 minutes (coinciding with uterine exteriorization), the patient presented a sudden episode of dyspnea, confusion, hypotension, and ST segment depression. The episode lasted approximately 10 minutes and resolved spontaneously with no sequelae. Neurological status and the electrocardiogram were normal at the end of surgery and no postoperative lesions were observed. In the immediate postoperative period, the patient presented a massive hemorrhage due to uterine atony. Echocardiography revealed a patent foramen ovale. The clinical signs in this patient are highly suggestive of a paradoxical cerebral and coronary air embolism.

Exclusion of Patients with Arteriosclerosis Reduces Long‐Term Recurrence Rate of Presumed Arterial Embolism after PFO Closure

Percutaneous transcatheter closure of patent interatrial communications after presumed paradoxical embolism is used as an alternative to surgery or long-term anticoagulation for the treatment of patients who are at risk for recurrent thromboembolism. To avoid atherosclerotic events to be judged as recurrent paradoxical embolism, we prospectively excluded all patients with detectable arteriosclerosis from our series and investigated long-term results. We report the outcome of 180 patients who underwent percutaneous transcatheter closure of patent foramen ovale (PFO), PFO like atrial septal defect (ASD), or an ASD because of paradoxical embolism. One hundred four patients had cerebral embolism, 57 had transient ischemic attacks, 16 coronary embolism, and 3 had peripheral embolism. Twenty-three patients experienced multilocal arterial embolism. One hundred twenty-five patients had a PFO, 63 of them with an atrial septal aneurysm (ASA), 24 a PFO-like ASD (7 of them with an ASA), and 31 had an ASD. After 18 months, only 5 patients (2.8%) showed a trivial residual shunt. At a mean follow-up of 40 months (range 4 to 88), resulting in 602 observed patient-years, only 1 patient experienced a presumed paradoxical (coronary) embolism (calculated annual risk to suffer a recurrent thromboembolic event: 0.16%). Percutaneous transcatheter closure of PFO/ASD is a safe and effective therapeutic option for the secondary prevention of presumed paradoxical embolism. It is associated with a high success rate, low incidence of hospital complications, and very low frequency of recurrent systemic embolic events.

Coronary arterial air embolus occurring during cesarean delivery

We present a case of a severe systemic (paradoxical) air embolism occurring during spinal anesthesia for cesarean delivery in an otherwise healthy 35-year-old parturient. Uncomplicated spinal anesthesia and satisfactory surgical anesthesia were obtained; no sedatives were used and the patient was awake and alert and tolerating the procedure well. Immediately following infant and placental delivery (approximately 25 min after the spinal anesthetic was induced) the patient had acute onset of markedly decreased mental status, profound ventricular ectopy and labile blood pressure. The event lasted for approximately 10 min with spontaneous resolution. Neurologic status returned to normal by the end of the surgery, but electrocardiogram findings in the immediate postoperative period were consistent with myocardial ischemia and serial cardiac troponin levels confirmed myocardial injury. On postoperative day 1, an echocardiogram demonstrated the presence of a patent foramen ovale. The events in this case are likely to be due to paradoxical coronary and cerebral air embolism.

Myocardial Ischemia: Atypical Presentation of an Atrial Septal Defect in Childhood

We describe a 17-year-old male with a secundum atrial septal defect (ASD), who presented with acute myocardial ischemia. The presumptive diagnosis of a paradoxical coronary embolism was based on the demonstration of a large ASD in conjunction with normal coronary arteries, a negative endomyocardial biopsy, and a negative drug screen. After percutaneous closure with an Amplatzer device, there has been no recurrence for 2 years.

Paradoxical coronary embolism causing non-ST segment elevation myocardial infarction in a case of pulmonary embolism

We describe the case of a 61-year-old woman who simultaneously suffered a pulmonary embolism and a myocardial infarction due to paradoxical coronary artery embolism. Transesophageal echocardiography with injection of agitated hydroxyethyl starch revealed a patent foramen ovale. Thrombophlebistis of the left saphenous vein with extension of thrombus into the femoral vein could be identified as the source of embolism. Paradoxical coronary embolism is an underrecognized cause of MI. Diagnosis is particularly difficult, when MI and PE coincide, because of the similarity in clinical signs and symptoms of both entities. A high level of clinical suspicion and echocardiography, especially if performed soon after presentation, can be the clue to early diagnosis of PDE.