Embolic renal infarct, patent foramen ovale and coronary artery dissection: a strange case of cardio-renal connection.

A 50-year-old female with no cardiovascular risk factors presented to our service for urgent coronary angiography because of an acute coronary syndrome with electrocardiographic inferior ST elevation. The coronary angiography revealed the occlusion of a small distal branch of the posterior interventricular artery in the total absence of even mild coronary atherosclerosis with a concomitant regional akinesia of the distal inferior left ventricular wall. The patient was referred to medical therapy with double antiplatelet therapy with aspirin and clopidogrel. The patient being still hypertensive despite therapy with nitrates and symptomatic for angina, a computed tomographic scan was performed, revealing no aortic dissection but a small right cortical renal infarct. A rise in creatinine greater than 25% (0.3 mg/dl) from baseline documented a condition of acute kidney injury class "R." Two days after, on control coronary angiography the branch of the posterior interventricular coronary appeared as a dissection of a branch of moderate calibre. The echocardiogram confirmed a distal inferior left ventricular wall akinesia with a preserved left ventricular ejection fraction, but more interestingly, revealed a patent foramen ovale (PFO) with massive right to left shunt after Valsalva manoeuvre and a moderate atrial septal aneurysm. Based on reported findings we hypothesized that a paradoxical embolism trough the PFO caused the renal infarct and a subsequent high blood pressure-induced coronary artery dissection.