Liang Kate, Williams Matthew, Bucciarelli-Ducci Chiara
Department of Cardiology, Bristol Heart Institute, University Hospitals Bristol and Weston NHS Foundation Trust, Upper Maudlin Street, Bristol, BS2 8HW, UK.
Faculty of Translational Health Sciences, Bristol Medical School, University of Bristol, 69 St. Michael's Hill, Bristol, BS2 8DZ, UK.
Eur Heart J Case Rep. 2022 Feb 1;6(2):ytac029. doi: 10.1093/ehjcr/ytac029. eCollection 2022 Feb.
Occurrence of paradoxical coronary embolism is reported in up to 10-15% of all myocardial infarctions but embolic infarctions presumed to be as a result of a patent foramen ovale (PFO) are rare. Although rare, it is important to identify these patients as they need appropriate investigations to confirm their diagnosis and guide further treatment.
We present the case of a gentleman with troponin positive chest pain with non-obstructed coronaries on invasive coronary angiogram. Subsequent cardiac magnetic resonance imaging (MRI) demonstrated multi-focal myocardial infarctions in several coronary artery territories. Further investigations including echocardiogram were performed in order to identify a cause and source of the embolic infarctions and led to the diagnosis of patent foramen ovale. The patient was treated as myocardial infarction with non-obstructed coronary arteries most likely due to embolic phenomena in the presence of a PFO.
Multiple focal infarctions in multiple coronary artery territories should raise the suspicion of an intra-cardiac shunt. Multi-modality imaging with cardiac MRI and echocardiogram is important in correctly identifying any source of emboli and the diagnosis of any intra-cardiac shunt. Whilst PFO closure is a possible treatment for patients, considerations regarding risk stratification and local provisions needs to be taken into account. Patients should be referred to the appropriate subspecialist to ensure suitable long-term follow-up.
据报道，在所有心肌梗死病例中，反常性冠状动脉栓塞的发生率高达10% - 15%，但推测由卵圆孔未闭（PFO）导致的栓塞性梗死却很罕见。尽管罕见，但识别这些患者很重要，因为他们需要进行适当的检查以确诊并指导进一步治疗。
我们报告了一位男性患者的病例，其肌钙蛋白阳性伴胸痛，侵入性冠状动脉造影显示冠状动脉无阻塞。随后的心脏磁共振成像（MRI）显示在几个冠状动脉区域有多灶性心肌梗死。为了确定栓塞性梗死的原因和来源，进行了包括超声心动图在内的进一步检查，结果诊断为卵圆孔未闭。该患者被当作冠状动脉无阻塞的心肌梗死进行治疗，最可能的原因是存在PFO时的栓塞现象。
多个冠状动脉区域出现多灶性梗死应引起对心内分流的怀疑。心脏MRI和超声心动图的多模态成像对于正确识别任何栓子来源和心内分流的诊断很重要。虽然PFO封堵是患者的一种可能治疗方法，但需要考虑风险分层和当地的条件。患者应转诊至合适的专科医生处，以确保进行适当的长期随访。
