ST-elevation myocardial infarction secondary to paradoxical coronary emboli in a patient with massive pulmonary embolism and essential thrombocytosis: A case report

Abstract

International Journal of Case Reports and Images (IJCRI) is an international, peer reviewed, monthly, open access, online journal, publishing high-quality, articles in all areas of basic medical sciences and clinical specialties.Aim of IJCRI is to encourage the publication of new information by providing a platform for reporting of unique, unusual and rare cases which enhance understanding of disease process, its diagnosis, management and clinico-pathologic correlations. Essential thrombocytosis (ET) is a myeloproliferative disorder with higher incidence of thrombotic events. To our knowledge, we present the first case of ST-segment elevation myocardial infarction (STEMI) secondary to paradoxical right coronary artery (RCA) embolus through a patent foramen ovale (PFO) in a patient with essential thrombocytosis and pulmonary embolus. Case Report: A 67-year old female with a history of ET presented to the emergency room with dyspnea. Physical examination revealed an elevated JVP, an S1Q3T3 pattern on her presenting ECG, and an elevated D-dimer. V/Q scan showed a high probability for pulmonary embolism as well as unusual evidence of right-to-left cardiac shunting. After starting low molecular weight heparin, she developed new-onset chest pain and her ECG showed ST-elevation in the inferior leads. Emergency left and right heart catheterization showed an acutely occluded RCA with heavy thrombus burden. This was managed successfully with thrombus aspiration only. Massive bilateral pulmonary embolism was seen on thoracic computed tomography (CT) scan, which was managed by systemic thrombolysis. A Transesophageal echocardiogram was performed, which confirmed a patent PFO with right-to-left shunting. The patient was treated medically with dual antiplatelets, anticoagulation with heparin and hydroxyurea. Given the degree of thrombotic burden PFO closure was not performed and the patient was managed conservatively with lifelong anticoagulation. The patient has been followed closely, and three years post-event, she has done remarkably well on warfarin with no evidence of further thromboembolism. Conclusion:We describe the first case of paradoxical coronary artery embolism through a PFO in a patient with ET and massive PE. Our patient was managed conservatively on oral anticoagulation without further thromboembolic events at three years post-event.