Clin Res Cardiol (2023). https://doi.org/10.1007/s00392-023-02180-w

A case report of myocardial infarction with non-obstructive coronary arteries (MINOCA) as the initial presentation of a patent foramen ovale (PFO)

A. J. Hobbach1, M. Indrasari2, H. Celik2, E. Poursanidou2, J. Schönewolf2, H.-P. Hobbach2

1Klinik für Kardiologie I, Universitätsklinikum Münster, Münster; 2Medizinische Klinik III - Kardiologie, Angologie und internistische Intensivmedizin, Kreisklinikum Siegen GmbH, Siegen;

Introduction: Although myocardial infarction with non-obstructive coronary arteries (MINOCA) has already been reported many years before, it has only recently been included in the European Society of Cardiology (ESC) guidelines of 2020. MINOCA is not a final diagnosis but rather a working hypothesis leading to further and careful diagnostics. MINOCA comprises a heterogenous group of causes, both coronary and non-coronary sources. Here, we report the case of a 40 years-old man with thromboembolic MINOCA as the initial presentation of a patent foramen ovale (PFO). Case Description: A 40 years-old man was admitted to emergency unit with acute chest pain. Dyspnea or vegetative symptoms were neglected. No previous illness was known, in particular no cardiovascular risk factors. Retrospectively, the patient remembered an earlier painful swelling of the right lower leg ten days ago, which he assessed as a sport injury and treated with sport absence without doctor consultation. An electrocardiogram (ECG) on admission showed changes of the ST-segment consistent with a posterolateral myocardial infarction (Figure 1). The cardiac markers troponin and N‐terminal pro‐brain natriuretic peptide (NT-pro-BNP) were elevated to 480 pg/ml and 135 pg/ml, respectively. Acute cardiac catheter examination was performed on the same day; laevocardiography revealed normal left ventricular (LV) ejection fraction (EF; EF: 58%) with mildly hypokinesis of the antero- and inferoapical LV segments. The coronary angiography showed normal coronary arteries but an embolic obliteration of the posterior descending artery (PDA) (Figure 2 A, B). Contrast transesophageal echocardiography (c-TEE) revealed a large pattern foramen ovale (PFO) (Figure 3 A, B), suggesting a thromboembolic coronary embolization in the PDA via the PFO. The patient was treated with dual antithrombotic therapy (Acetylsalicylic acid (100 mg/d) and Clopidogrel (75 mg/d)). One week after the initial admission, he underwent percutaneous transcatheter closure of PFO. Discussion: MINOCA is present in about 5% to 25% patients with acute coronary syndrome. Guidelines recommend the need for further and careful diagnosis of the underlying causes of MINOCA to improve the patient’s prognosis and to prevent further events. Coronary embolism occurs in 2.9% of acute myocardial infarction and is primarily caused by thromboembolism. Cardiac thromboembolism is often associated with an intracardiac right-to-left-shunts. One of the most frequent right-to-left-shunts is a PFO with 25% prevalence of the healthy population. If PFO is found to be the primary cause of systemic or cardiac embolism, a percutaneous closure of the PFO is recommended. Our case draws attention to consider paradox embolism via a PFO as a non-coronary cause of MINOCA. 1: Electrocardiogram (ECG) on admission. A, B: ST-segment elevations in leads II, III, aVF, V5 and V6; reciprocal ST-segment depressions in leads aVL, V1 and V2, compatible with a posterolateral myocardial infarction.    2: Coronary angiography. A: Persistence of contrast medium (red arrow) in the posterior descending artery (PDA) at the thrombus localization. B: PDA with distal contrast discontinuation (red arrow) due to thrombotic occlusion. 3: Patent foramen ovale (PFO) in contrast transesophageal echocardiography (c-TEE). A: Contrast medium (red arrow) passing from the right atrium (RA) into the left atrium (LA) via the PFO. B: Contrast medium in the LA (red arrow). AV; aortic valve.

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