Catheter-Based Closure of the Patent Foramen Ovale

Case presentation: A 34-year-old woman was admitted for chest pain lasting 5 hours. She had been in excellent health except for migraine attacks with rare aura that kept her away from work about twice a month. She took no medication except for birth control pills. The ECG was unrevealing, but cardiac biomarkers were elevated. Emergency cardiac catheterization showed an occluded small left circumflex coronary artery (Figure 1) and a corresponding small akinetic area in the left ventriculogram. No attempt at coronary recanalization was made because the symptoms had abated, the injured myocardium was akinetic, and there were no collaterals. However, a catheter was introduced into the right atrium, and contrast medium injection proved the suspected patent foramen ovale (PFO; Figure 2 and Movies I and II in the online-only Data Supplement). An Amplatzer PFO occluder was implanted in <10 minutes. The patient was discharged 36 hours later after her cardiac biomarkers had normalized. Figure 1. Right anterior oblique view of the left coronary artery showing an abrupt occlusion (presumably embolic) of a small left circumflex coronary artery (arrow).Figure 2. Left, Angiographic proof of a PFO (dashed arrow) by contrast medium injection at the PFO entrance in the right atrium (RA). Right, Situation after implantation of an Amplatzer 25-mm PFO occluder (left atrium [LA] disk, 25 mm; RA disk, 18 mm). See also Movies I and II in the online-only Data Supplement. SS indicates septum secundum; SP, septum primum.Several lessons are to be gleaned from this case: (1) paradoxical embolism does not necessarily require clinically apparent deep vein thrombosis; (2) paradoxical embolism is not confined to the brain; (3) if coronary artery disease had been present, the connection to paradoxical embolism would probably have been missed; (4) attention was correctly directed primarily at the PFO with a potential to …