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Case Report
 
ST-elevation myocardial infarction secondary to paradoxical coronary emboli in a patient with massive pulmonary embolism and essential thrombocytosis: A case report
Fahad S. Almehmadi1, Albayda M. Mehdar2, Kumar Sridhar3, Patrick Teefy4
1MBBS, FRCPC, Adult Cardiology Resident, Department of Medicine, University of Toronto, Toronto, Ontario, Canada, Adult Cardiology Scholar at King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia.
2MBBS, Internal Medicine Resident, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
3MD, FRCPC, Associate Professor, Department of Medicine, University of Western Ontario, London, Ontario, Canada.
4MD, FRCPC, Associate Cardiology Professor, Department of Medicine, University of Western Ontario, London, Ontario, Canada.

doi:10.5348/ijcri-201528-CR-10489

Address correspondence to:
Dr. Fahad Saleh Almehmadi
Adult Cardiology Program, University of Toronto
2305-1055 Bay Street, Toronto
Ontario, M5S 3A3
Canada
Phone: 416-567-5516

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How to cite this article
Almehmadi FS, Mehdar AM, Sridhar K, Teefy P. ST-elevation myocardial infarction secondary to paradoxical coronary emboli in a patient with massive pulmonary embolism and essential thrombocytosis: A case report. Int J Case Rep Images 2015;6(3):149–155.


Abstract
Introduction: 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.

Keywords: Essential thrombocytosis, Myocardial infarction, Paradoxical embolism, Patent foramen ovale, Pulmonary embolism


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Author Contributions
Fahad S. Almehmadi – Conception and design, Drafting the article, Critical revision of the article, Final approval of the version to be published
Albayda M. Mehdar – Conception and design, Drafting the article, Critical revision of the article, Final approval of the version to be published
Kumar Sridhar – Analysis and interpretation of data, Drafting the article, Critical revision of the article, Final approval of the version to be published
Patrick Teefy – Acquisition of data, Analysis and interpretation of data, Drafting the article, Critical revision of the article, Final approval of the version to be published
Guarantor of submission
The corresponding author is the guarantor of submission.
Source of support
None
Conflict of interest
Authors declare no conflict of interest.
Copyright
© 2015 Fahad S. Almehmadi et al. This article is distributed under the terms of Creative Commons Attribution License which permits unrestricted use, distribution and reproduction in any medium provided the original author(s) and original publisher are properly credited. Please see the copyright policy on the journal website for more information.



About The Authors

Fahad S. Almehmadi is a second year Adult Cardiology Resident at University of Toronto in Canada. He earned his medical degree with distinction from Umm Alqura University in Makkah, Saudi Arabia. He intends to pursue an academic career in cardiology and cardiac electrophysiology.



Albayda M. Mehdar is a second year Internal Medicine Resident at University of Toronto in Canada. She earned her medical degree with distinction from King Abdulaziz University in Jeddah, Saudi Arabia.



Kumar Sridhar is Associate Professor at Western University - Department of Medicine and University Hospital and Interventional Cardiologist and Director of CCU at London Health Sciences Centre. Dr. Sridhar completed his medical training at Western University, London, Ontario and his interventional cardiology fellowship at Western University and Thomas Jefferson University Hospital in Philadelphia, Pennsylvania. He has a number of publications in peer-reviewed journals, book chapters and research interests specific to novel treatment coronary interventions and treatment strategies.



Patrick Teefy is Director of the Cardiac Catheterization Laboratories at London Health Sciences Centre, London, Ontario Canada and Associate Professor, University of Western Ontario. His research interests include interventional cardiology and trans-catheter aortic valve implantation.