Patent foramen ovale and paradoxical coronary artery embolism: rare event with great clinical relevance

Patent foramen ovale (PFO) is the most common structural cardiac anomaly associated with paradoxical embolism. Conditions increasing right heart chambers pressure, such as pulmonary embolism, can lead to its opening with increased risk of passage of thrombi from the venous to arterial circulation. Paradoxical embolism is a rare event with a possible severe prognosis. This case report is focused on a 77-year-old woman who was transported to the Emergency Department because of dyspnea, confusion, and chest pain with cardiogenic shock. The ECG showed a signifi cant ST-T elevation in the high lateral leads. Both echocardiographic and clinical data suggested massive pulmonary embolism and consequent paradoxical embolism through a PFO, causing acute myocardial infarction. Immediate fi brinolytic therapy was performed; infusion was complicated by pulseless electrical activity leading to death despite adequate advanced life support. The report discusses the importance of carefully evaluating and recognizing the signs and symptoms of paradoxical coronary and peripheral embolism, secondary to pulmonary embolism, in patients with PFO.