Connect
MJA
MJA

Paradoxical embolism through patent foramen ovale as a cause of myocardial infarction

Naim Mridha, Eloise Ward, Samual Hayman, Arun Dahiya and Sandhir Prasad
Med J Aust 2021; 215 (2): . || doi: 10.5694/mja2.51140
Published online: 19 July 2021

A 42‐year‐old man presented with acute onset substernal chest pain. His only cardiac risk factor was mild, medicated dyslipidaemia and he was a lifelong non‐smoker. He had a healthy body mass index and exercised regularly. There was no history of previous thromboembolic events or known haematological disease. On arrival to the emergency department, he was haemodynamically stable. Electrocardiogram initially showed sinus rhythm with biphasic anterior lead T wave inversion that resolved before angiogram (Box 1). Cardiac high sensitivity troponins were positive, peaking at 2479 ng/L (reference range, < 20 ng/L), while the remaining laboratory tests, including white cell count and inflammatory markers, were unremarkable. Telemetry throughout admission did not identify arrhythmia. Coronary angiography to investigate the source of the troponin leak showed normal coronary arteries (Box 2). Subsequent cardiac magnetic resonance imaging scan revealed localised hypokinesia of mid‐anteroseptum and apical cap with non‐contiguous subendocardial late gadolinium enhancement in mid‐septum and distal cap (Box 3), raising the possibility of embolic events. Transthoracic echocardiogram demonstrated regional wall motion abnormalities with mid‐anteroseptal and apical hypokinesis, with an early positive agitated saline bubble study and evidence of right‐to‐left shunt suspicious of patent foramen ovale (PFO). Subsequent transoesophageal echocardiogram confirmed moderate sized PFO with shunt present both at rest and after Valsalva manoeuvre. Ultrasound of the lower limbs showed superficial saphenous vein thromboembolism (unprovoked) but no deep vein thrombosis. Remaining investigations, including a thrombophilia screen, were unremarkable. After discussion with the patient, he was commenced on anticoagulation for 2 months until he underwent successful percutaneous PFO closure, at which point he was transitioned to antiplatelet therapy.

  • Naim Mridha1,2
  • Eloise Ward1,3
  • Samual Hayman1,3
  • Arun Dahiya1,2
  • Sandhir Prasad1,3

  • 1 Royal Brisbane and Women’s Hospital, Brisbane, QLD, Australia
  • 2 Griffith University, Gold Coast, QLD, Australia
  • 3 University of Queensland, Brisbane, QLD, Australia



Competing interests:

No relevant disclosures.

Author

remove_circle_outline Delete Author
add_circle_outline Add Author

Comment
Do you have any competing interests to declare? *

I/we agree to assign copyright to the Medical Journal of Australia and agree to the Conditions of publication *
I/we agree to the Terms of use of the Medical Journal of Australia *
Email me when people comment on this article

Online responses are no longer available. Please refer to our instructions for authors page for more information.