Occam's Razor in Action: Simultaneous Pulmonary Embolism and Acute Myocardial Infarction Secondary to a Previously Undiagnosed Patent Foramen Ovale

1Mayo Clinic Arizona, Phoenix, AZ

Meeting: Hospital Medicine 2007, May 23-25, Dallas, Texas

Abstract number: 111

Case Presentation:

A 79‐year‐old man with no antecedent coronary artery disease underwent resection of recurrent high‐grade lipo‐sarcoma of the right upper extremity with placement of hollow catheters for perioperative brachytherapy. On postoperative day 2, he developed acute chest pain with dyspnea and hypoxia. On examination, the patient was alert and oriented, but diaphoretic and in moderate distress. His pulse was 84, blood pressure was 230/120 mm Hg, and oxygen saturation was 93% on 4 L O2/min by nasal cannula. His cardiac rhythm was regular, and his lungs were clear. ECG demonstrated new ST segment elevation in leads III and aVF suggestive of ST elevation myocardial infarction (STEMI). At this point the available data pointed strongly to either PE with secondary ECG changes or STEMI with chest pain and hypoxia, a diagnostic and therapeutic dilemma. Heparin was initiated, and the patient went for an emergent angio‐gram, which showed a “cutoff sign” in the distal left anterior descending artery (LAD) and new apical hypokinesis. The remaining coronary arteries were unremarkable. Because paradoxical embolism was suspected, right heart catheterization was performed, which identified a previously undiagnosed patent foramen ovale (PFO). A subsequent spiral CT thorax revealed bilateral PEs.

Discussion:

PFOs are a common entity, with an estimated prevalence of 26% in the general population. In the hospital setting, the mortality of patients with acute PE and PFO‐associated paradoxical embolism is 5‐fold higher than that of patients with PE but no PFO. Paradoxical embolism through a PFO is widely accepted as a cause of cryptogenic stroke and peripheral vascular thrombotic occlusion. Less common, and therefore less well known to the practicing hospitalist, are paradoxical emboli to the coronary artery, which account for only 5%‐10% of all paradoxical emboli and are described in only a handful of case reports. In ourvignette, the pathognomonic finding of a LAD “cutoff” sign seen on angiography provided direct evidence of a paradoxical embolism, enabling diagnosis of PFO during right heart catheterization.

Conclusions:

Acute PE and acute myocardial infarction are both very common diagnoses in the hospital and are frequently in the same differential diagnosis. We have presented a case in which Occam's razor holds true, in that there is one unifying albeit unusual explanation for both these clinical entities coexisting in the same patient. Recognition of paradoxical emboli via a PFO manifesting as PE and acute MI is rare but essential for the hospitalist to consider when posed with a patient presenting with acute hypoxia and ECG changes.

Author Disclosure:

A. Budavari, None; K. K. Will, None; J. Wilkens, None.

To cite this abstract:

Budavari A, Will K, Wilkens J. Occam's Razor in Action: Simultaneous Pulmonary Embolism and Acute Myocardial Infarction Secondary to a Previously Undiagnosed Patent Foramen Ovale. Abstract published at Hospital Medicine 2007, May 23-25, Dallas, Texas Abstract 111. Journal of Hospital Medicine. 2007; 2 (suppl 2). https://www.shmabstracts.com/abstract/occams-razor-in-action-simultaneous-pulmonary-embolism-and-acute-myocardial-infarction-secondary-to-a-previously-undiagnosed-patent-foramen-ovale/. Accessed September 22, 2019.

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