PRACA KAZUISTYCZNA

Paradoxical emboli as a rare cause of myocardial infarction: treatment and prophylaxis

Zator skrzyżowany jako rzadka przyczyna zawału serca — leczenie i profilaktyka

Robert Sabiniewicz1, Jarosław Meyer-Szary1, Dariusz Ciećwierz2, Miłosz Jaguszewski2

1Department of Pediatric Cardiology and Congenital Heart Disease, Medical University of Gdansk, Poland

2Department of Cardiology Medical, University of Gdansk, Poland

Address for correspondence: dr n. med. Jarosław Meyer-Szary, Katedra i Klinika Kardiologii Dziecięcej i Wad Wrodzonych Serca, Gdański Uniwersytet Medyczny, ul Dębinki 7, Gdańsk 80–210, tel. 58 349 28 82, e-mail: jmeyerszary@gumed.edu.pl

Case report

A 58-year-old male with a history of primary hypertension, obstructive sleep apnea and cerebrovascular disease with two major ischemic strokes and several episodes consistent with transient ischemic attacks (TIA) referred to our hospital suffering acute angina. Electrocardiogram and cardiac markers at presentation were diagnostic for the lateral ST-segment elevation myocardial infarction (STEMI). Urgent coronary angiography revealed a significant thrombus in the intermediate branch of the left coronary artery (Figure 1A, arrow) with no significant atherosclerosis. The subsequent thrombectomy was carried out with an excellent result and final TIMI grade flow 3 (Figure 1B).

Figure 1A, B. Coronary angiography

Previous brain computed tomography (CT) and magnetic resonance imaging (MRI) examinations revealed 6 × 2 cm ischemic focus in occipito-temporal cortex and multiple smaller foci in both cerebral hemispheres and cerebellum. Trans-cranial Doppler (TCD) was strongly positive and transesophageal echocardiography (TEE) revealed a patent foramen ovale (PFO) with a right-to-left shunt using agitated saline contrast. Standard coagulogram and lower extremities Doppler examination were negative. Thus, the hypothesis of paradoxical emboli as a cause of both STEMI and cerebral infarctions appeared strongly evidenced and the patient was started on clexane and warfarin. Four weeks following the initial admission, the patient underwent successful percutaneous implantation of the Occlutech PFO closure device and anticoagulation therapy was reduced to aspirin. Further clinical course was uneventful at three and a half years.

Discussion

Thromboemboli originating in the venous system may appear in the systemic circulation crossing the PFO and cause major adverse cardiac and cerebrovascular events (major adverse cardiovascular and cerebrovascular events [MACCE]) including death, myocardial infarction (MI), revascularization, stroke/TIA as well as migraines with aura. Large body of literature found a prevalence of PFO of 44% to 66% in a cryptogenic stroke subsets [1]. Substantially higher rate of PFO in patients with a cryptogenic stroke as compared to these found in the autopsy all-cause series (27%) suggests that at least in some part, the cause of stroke might be paradoxical thromboembolism [1]. On the other hand, in light of current knowledge and scarce data regarding the performance of occluder devices to prevent cerebrovascular adverse events, this approach is still the matter of debate [2–4]. The presented paradoxical embolism exemplifies a rare cause and a potential mechanism of MI where no significant coronary atherosclerosis was documented in coronary angiography. This most often occurs in the presence of additional triggering factors leading to coagulopathies [5], elevated right atrial pressure i.e. mechanical ventilation [6], sleep apnea [7], right ventricular failure of varied origin including massive pulmonary emboli [8], pulmonary hypertension, congenital heart diseases comprising Ebstein anomaly or those leading to Eisenmenger syndrome or single ventricular hearts [9].

Conclusions

Herein, we present a rare case of spontaneous paradoxical embolization as a potential cause of MI. This case depicts, that the paradoxical embolisation has to be always considered in differential diagnosis during acute MI. Therefore, the presence of PFO should be extensively evaluated during MI using available imaging technics, especially in young patients, to prevent the following MACCE.

Conflict of interest

None.

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