We report the case of a 51 year old male, smoker of about 20 cigarettes/day and with history of uninvestigated headache.
In March 2023 he arrived in the Emergency Department for oppressive retrosternal chest pain radiating to the left arm; the electrocardiogram (ECG) showed sinus rhythm, no acute ST segment changes; HS troponin T was elevated. Transthoracic echocardiogram showed 55% EF, no kinesis defects, no major valvulopathy, neither pericardial effusion.
The patient was admitted to the ICU with a diagnosis of NSTE myocardial infarction.
Despite on admission HS troponin T HS was further increased and ECG evolved with inferior and lateral subepicardial ischemia, coronary angiogram showed normal coronary arteries, with an area of haziness in the right coronary artery.
To investigate the etiology of myocardial damage the patient underwent cardiac MRI, that showed a left ventricle with normal size and mildly reduced systolic function; inferior apical and septal segment were akinetic; right ventricle was normal with preserved systolic function; edema and fibrosis with ischemic pattern was seen in the inferior apical and septal segment.
Then we looked for embolic sources: continuous ECG monitoring excluded supraventricular arrhythmias. We performed echocardiogram that raised suspicion of a patent foramen ovale (PFO) confirmed on transesophageal contrast echocardiogram.
Brain MRI showed no obvious changes compatible with recent ischemic lesions; few millimeters focal hyperintense areas in T2 and FLAIR, of gliotic nonspecific significance were reported in the frontal subcortical white matter bilaterally, left parietal and in the right corona radiata.
We concluded for diagnosis of paradoxical coronary embolism and the patient was treated with percutaneous closure of PFO: by right femoral vein route and under intracardiac ultrasound guidance, closure of PFO was performed with Amplatzer No. 25 with excellent fluoroscopic and final ultrasound result.
The broad spectrum of the possible cause of myocardial injury in MINOCA makes defining the extact underlying etiology challenging, but correctly knowing the culprit mechanism improves therapies and outcome; paradoxical coronary embolism due to a patent foramen ovale is rarely diagnosed; in our clinical case integrated multimodality imaging diagnostic work up, proved highly effective in identifying the cause of the myocardial damage and allowed the appropriate treatment.
