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      Concomitant acute stroke, pulmonary and myocardial infarction due to in-transient thrombus across a patent foramen ovale

      , MD, , MD, , MD, , MD

      Echo Research and Practice

      Bioscientifica Ltd

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          Summary Non-atherosclerotic myocardial infarction (MI) is an important but often misdiagnosed cause of acute MI. Furthermore, non-atherosclerotic MI with concomitant acute stroke and pulmonary embolism due to in-transit thrombus across a patent foramen ovale (PFO) is a rare but potentially fatal combination (1, 2, 3). Early detection of this clinical entity can facilitate delivery of targeted therapies and avoid poor outcome (1, 2). Here, we describe a 68-year-old female with hypertension, tobacco abuse and chronic obstructive pulmonary disease presenting with facial droop, right arm weakness and aphasia. Head computed tomography (CT) without contrast was unremarkable. ECG showed an acute inferolateral ST-elevation MI (Fig. 1, Panel A). As patient presented with both an acute neurological deficit and MI, clinical suspicion of non-atherosclerotic MI was raised and the patient underwent concurrent emergency coronary angiography (CAG) and transesophageal echocardiogram (TEE). TEE revealed highly mobile masses in the left and right atrium (Fig. 1, Panel B and Video 1). The large mass (thrombus or cast of a deep venous thrombus) was caught in a PFO (Fig. 1, Panel C, D, E and Videos 2, 3). A second smaller mass/thrombus was seen on the Eustachian valve near the right atrial/inferior vena cava junction (Fig. 1, Panel F and Video 4). CAG confirmed a 100% occluded distal right posterolateral artery suggestive of an embolic phenomenon. The patient underwent successful thrombectomy, retrieving a large thrombus burden (Fig. 1, Panel G and Videos 5, 6, 7). CT angiography showed occluded internal carotid artery (Fig. 1, Panel H). Pathology from thrombectomy confirmed fibrin-rich thrombus. The patient had bilateral lower extremity deep vein thrombosis and bilateral diffuse pulmonary embolisms. Figure 1 (A) ECG showing an acute inferolateral ST-elevation MI; (B) TEE bicaval view revealing a highly mobile mass in the left and right atrium; (C) TEE four-chamber view showing a large thrombus across a PFO; (D) TEE bicaval with color Doppler showing a shunt across the interatrial septum; (E) 3D-TEE showing irregular shape of the thrombus; (F) TEE at lower-esophageal level showing a second smaller thrombus on the Eustachian valve; (G) CAG confirming 100% occluded distal right posterolateral artery; (H) CT angiography showing occluded internal carotid artery. Video 1 TEE bicaval revealing a highly mobile mass in both atria. View Video 1 at Download Video 1 Video 2 TEE four-chamber view showing the large thrombus that was caught in a PFO. View Video 2 at Download Video 2 Video 3 3D-TEE showing a large thrombus in the left atrium. View Video 3 at Download Video 3 Video 4 TEE showing a second smaller thrombus on the Eustachian valve. View Video 4 at Download Video 4 Video 5 CAG confirming 100% occluded distal right posterolateral artery. View Video 5 at Download Video 5 Video 6 CAG during thrombus aspiration. View Video 6 at Download Video 6 Video 7 CAG showing restored TIMI III flow in the vessel. View Video 7 at Download Video 7 Declaration of interest The authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of this article. Funding This work did not receive any specific grant from any funding agency in the public, commercial, or not-for-profit sector. Patient consent Images are anonymized. Permission to publish was obtained from a relative. Author contribution statement Contribution to the patient care: Sergio Barros-Gomes; Abdallah El Sabbagh; Mackram F Eleid; Sunil V Mankad. Study design, conception and writing the manuscript: Sergio Barros-Gomes and Sunil V Mankad. Revision of the manuscript: Sergio Barros-Gomes; Abdallah, El Sabbagh; Mackram F Eleid; Sunil V Mankad.

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          Most cited references 3

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          Paradoxical embolism.

          Paradoxical embolism is an important clinical entity among patients with venous thromboembolism in the presence of intracardiac or pulmonary shunts. The clinical presentation is diverse and potentially life-threatening. Although the serious nature and complications of paradoxical embolism are recognized, the disease entity is still rarely considered and remains under-reported. This paper provides an overview on the different clinical manifestations of paradoxical embolism, describes the diagnostic tools for the detection of intracardiac and pulmonary shunts, reviews therapeutic options, and summarizes guideline recommendations for the secondary prevention of paradoxical embolism.
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            Coronary artery embolism and myocardial infarction.

            Although coronary artery embolism is a recognized entity, there is little morphologic information indicating it is a cause of myocardial infarction. We studied patients with coronary artery embolic infarcts, which comprised 13% of our autopsy-studied infarcts. Underlying diseases predisposing to coronary emboli included valvular heart disease (40%), myocardiopathy (29%), coronary atherosclerosis (16%), and chronic atrial fibrillation (24%). Mural thrombi were present in 18 (33%). Myocardial infaction, clinically diagnosed in 15 (27%) patients, caused death in 11 (20%). Most emboli involved the left coronary artery and lodged distally, causing infarcts that were usually transmural. Because of their distal location and recanalization, coronary emboli may be a cause of infarcts with angiographically normal coronaries. Thus, coronary emboli are not rare, may produce signs and symptoms indistinguishable from altherosclerotic coronary disease, and by lodging distally in coronary arteries that are usually previously normal, they most often cause small but transmural myocardial infarction.
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              Acute myocardial infarction with concomitant pulmonary embolism as a result of patent foramen ovale

              Acute myocardial infarction (MI) and pulmonary embolism canal one lead to life-threatening conditions such as sudden cardiac death and congestive heart failure. We discuss a case of a 74-year-old man presented to the emergency department with acute dyspnea and chest pain. Acute anterior MI and pulmonary embolism concomitantly were diagnosed. Primary percutaneous coronary intervention performed because of preliminary acute anterior MI diagnosis. Transthoracic echocardiography was performed to determine further complications caused by acute MI because patient had a continuous tachycardia and dyspnea although hemodynamically stable. Transthoracic echocardiography revealed a thrombus that was stuck into the patent foramen ovale with parts in right and left atria. Anticoagulation therapy was started; neither fibrinolytic therapy nor operation was performed because of low survey expectations of the patient's recently diagnosed primary disease stage IV lung cancer. Patient was discharged on his 20th day with oral anticoagulation and antiagregant therapy.

                Author and article information

                Echo Res Pract
                Echo Res Pract
                Echo Research and Practice
                Bioscientifica Ltd (Bristol )
                December 2018
                08 August 2018
                : 5
                : 4
                : I9-I10
                Division of Cardiovascular Diseases , Mayo Clinic, Rochester, Minnesota, USA
                Author notes
                Correspondence should be addressed to S V Mankad: mankad.sunil@
                © 2018 The authors

                This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

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