[Downloaded free from http://www.heartviews.org on Thursday, April 02, 2015, IP: 197.35.205.244] || Click here to download free Android application for this journal Case Report Paradoxical Coronary Artery Embolism ‑ A Rare Cause of Myocardial Infarction Fayaz A. Hakim, Evan P. Kransdorf, Muaz M. Abudiab, John P. Sweeney Department of Medicine, Division of Cardiovascular Diseases, Mayo Clinic, Scottsdale, Arizona, USA ABSTRACT Paradoxical coronary artery embolism is a rare, but often an underdiagnosed cause of acute myocardial infarction. It should be considered in patient who presents with chest pain and otherwise having a low risk profile for atherosclerosis coronary artery disease. We describe a case of paradoxical coronary artery embolism causing ST segment elevation myocardial infarction in a patient with upper extremity venous thrombosis. Echocardiography demonstrated a patent foramen ovale (PFO) with bidirectional shunt. In addition to treatment of acute coronary event closure of the PFO should be considered to prevent a recurrence. Key words: Coronary artery, embolism, flush occlusion, myocardial infarction, paradoxical How to cite this article: Hakim FA, Kransdorf EP, Abudiab MM, Sweeney JP. Paradoxical coronary artery embolism - A rare cause of myocardial infarction. Heart Views 2014;15:124-6. © Gulf Heart Association 2014. INTRODUCTION elevation in inferior (II, III, and aVF) leads. Cardiac biomarkers were elevated (Troponin-T 2.230 ng/ml oronary artery embolism is an established (normal <0.01 ng/ml) and creatine kinase myocardial cause of acute coronary syndrome, but band fraction 65.1 ng/ml (normal <6.7 ng/ml)). Coronary Cparadoxical coronary artery embolism causing angiography revealed flush occlusion of the posterior myocardial infarction is rare and requires a high descending artery and posterolateral branch of the degree of clinical suspicion for diagnosis. Recognition right coronary artery [Figure 1b, arrows]. Severe of this condition is important as these patients are thrombocytopenia (platelet count 37 × 109/L) secondary at risk of future fatal embolic phenomena. A search to newly diagnosed heparin-induced thrombocytopenia for venous thrombosis and underlying prothrombotic precluded use of antiplatelet agents and hence, coronary conditions should be undertaken. Percutaneous intervention. Bivalirudin was initiated for anticoagulation. device closure of interatrial communication either Chest pain and echocardiographic changes resolved. in the form of patent foramen ovale (PFO) or atrial Transesophageal echocardiography with septal defect (ASD) should be considered to prevent agitated saline showed a small PFO (Figure 1c, future embolism. arrow) with bidirectional shunt seen on color Doppler imaging [Figure 1d, asterix]. In addition, a large thrombus CASE REPORT was seen in the superior vena cava [Figure 1e, arrow]. A diagnosis of ST elevation myocardial infarction A 64-year-old male with multiple myeloma was admitted secondary to paradoxical embolism to the right coronary for autologous stem cell transplantation. Two weeks artery was entertained. previous he was diagnosed with a peripherally inserted In addition to long-term treatment with fondaparinux central catheter (PICC)-related right basilic and axillary for venous thrombosis, percutaneous PFO closure was vein thrombosis [Figure 1a, arrows] complicated recommended to prevent recurrent embolism. by pulmonary embolism that was treated with low molecular weight heparin. Access this article online During an attempt at PICC removal, the patient Quick Response Code: coughed and developed sudden severe left-sided Website: chest pain. An electrocardiogram showed ST segment www.heartviews.org Dr. Fayaz Ahmad Hakim, Address for correspondence: DOI: Mayo Clinic College of Medicine 13400 E Shea Blvd, Scottsdale, Arizona 85259, USA. 10.4103/1995-705X.151089 E‑mail: [email protected] HEART VIEWS 124 Oct-Dec 14 Issue 4 / Vol 15 [Downloaded free from http://www.heartviews.org on Thursday, April 02, 2015, IP: 197.35.205.244] || Click here to download free Android application for this journal Hakim, et al.: Coronay artery embolism a b c d e Figure 1: (a) Doppler ultrasound of axillary vein showing a thrombus. (b) Right coronary angiogram showing flush occlusion of posterior descending artery and posterolateral branch of right coronary artery. (c) Transesophageal echocardiography (TEE) with agitated saline showing bubbles crossing the patent foramen ovale (PFO). (d) TEE with Doppler study showing shunting across the PFO. (e) TEE showing a thrombus in superior vena cava DISCUSSION with identification of a venous source of embolus and lack of thrombi in the left heart fulfill the criteria for presumptive Paradoxical coronary embolism is rare and accounts diagnosis of this condition.[4] A definite diagnosis requires for 10–15%.[1] of all paradoxical emboli, and 25% of demonstration of thrombus across the venoarterial acute coronary events in patients less than 35 years of communication either by echocardiography or contrast age.[2] Our patient had a documented PICC associated computed tomographic angiography of the chest. thrombus, and an episode of cough preceding the onset Many times paradoxical coronary artery embolism of chest pain caused transient elevation in right atrial can only be made at the time of autopsy. When suspected pressure with right to left shunting and paradoxical clinically, a search for an underlying condition predisposing embolism though a PFO. The Valsalva maneuver is to venous thrombosis should be undertaken. routinely used to demonstrate shunting across the PFO The management of acute coronary syndrome during echocardiographic examination in individuals in caused by paradoxical coronary artery embolism is similar whom spontaneous shunting is not seen. to that occurring in the setting of atherosclerotic coronary Paradoxical embolism was first reported by artery disease. Manual aspiration thrombectomy with or Cohnheim in 1877[3] and is known to cause cerebral, without angioplasty and stenting followed by aggressive peripheral arterial, and in rare instances coronary medical management including antiplatelet agents, artery occlusion. Paradoxical coronary artery embolism is the standard of practice. Anticoagulation therapy should be suspected in patients who otherwise are at should be started for established venous thrombosis.[5] low risk for atherosclerotic coronary artery disease. In The management of patients with contraindication to a given clinical scenario, demonstration of venoarterial antiplatelet therapy may be challenging as in this case. communication (most often at the atrial level) together Aspiration and manual thrombectomy should be the 125 HEART VIEWS Oct-Dec 14 Issue 4 / Vol 15 [Downloaded free from http://www.heartviews.org on Thursday, April 02, 2015, IP: 197.35.205.244] || Click here to download free Android application for this journal Hakim, et al.: Coronay artery embolism main therapeutic intervention in such a situation unless REFERENCES the embolus is distal in a small coronary artery. Measures to prevent recurrence should be 1. Wachsman DE, Jacobs AK. Paradoxical coronary embolism: considered. Optimum therapeutic strategy in preventing A rare cause of acute myocardial infarction. Rev Cardiovasc Med recurrent embolic events in patients with PFO is not 2003;4:107‑11. 2. Velebit V, al‑Tawil D. Myocardial infarct in a young man with established. A recent meta-analysis of three randomized angiographically normal coronary arteries and atrial septal defect. clinical trials addressing the role of transcutaneous Med Arh 1999;53:33‑6. closure of PFO showed a benefit in preventing recurrent 3. Cohnheim J. Thrombose und Embolie. In: Vorlesungen Über cerebrovascular ischemic events in patients with Allgemeine Pathologie. Berlin: Hirschwald; 1877. p. 134. cryptogenic stroke when compared with medical 4. Johnson BI. Paradoxical embolism. J Clin Pathol 1951;4:316‑32. therapy.[6] Another study demonstrated lower recurrent 5. Wilson AM, Ardehali R, Brinton RJ, Yeung AC, Vagelos R. Successful removal of a paradoxical coronary embolus using an neurological event rates with Amplatzer compared with aspiration catheter. Nat Clin Pract Cardiovasc Med 2006;3:633‑6. [7] CardioSeal‑STARflex and Helex devices. Although 6. Rengifo‑Moreno P, Palacios IF, Junpaparp P, Witzke CF, Morris DL, percutaneous device closure has not been studied in Romero‑Corral A. Patent foramen ovale transcatheter closure vs. paradoxical coronary embolism, it should be considered medical therapy on recurrent vascular events: A systematic review to prevent fatal recurrent events. and meta‑analysis of randomized controlled trials. Eur Heart J In summary, paradoxical coronary embolism is a 2013;34:3342‑52. rare cause of acute coronary syndrome. Once suspected, 7. Hornung M, Bertog SC, Franke J, Id D, Taaffe M, Wunderlich N, et al. Long‑term results of a randomized trial comparing three careful transesophageal echocardiographic examination different devices for percutaneous closure of a patent foramen is important for presumptive diagnosis. In addition to ovale. Eur Heart J 2013;34:3362‑9. acute management of acute coronary syndrome, PFO closure to prevent recurrent thromboembolism should Source of Support: Nil, Conflict of Interest: None declared. be considered. New features on the journal’s website Optimized content for mobile and hand-held devices HTML pages have been optimized of mobile and other hand-held devices (such as iPad, Kindle, iPod) for faster browsing speed.