Concomitant acute stroke, pulmonary and myocardial infarction due to in-transient thrombus across a patent foramen ovale.

Non-atherosclerotic myocardial infarction (MI) is an important but often misdiagnosed cause of acute MI. Furthermore, non-atherosclerotic MI with concomitant acute stroke and pulmonary embolism due to in-transit thrombus across a patent foramen ovale (PFO) is a rare but potentially fatal combination (1-3). Early detection of this clinical entity can facilitate delivery of targeted therapies and avoid poor outcome (1, 2). Here, we describe a 68-year-old female with hypertension, tobacco abuse, and chronic obstructive pulmonary disease presenting with facial droop, right arm weakness and aphasia. Head computed tomography (CT) without contrast was unremarkable. ECG showed an acute inferolateral ST-elevation MI (Panel A). As patient presented with both an acute neurological deficit and MI, clinical suspicion of non-atherosclerotic MI was raised and the patient underwent concurrent emergency coronary angiography (CAG) and transesophageal echocardiogram (TEE). TEE revealed highly mobile mass in the left and right atrium (Panel B, Video S1). The large mass (thrombus or cast of a deep venous thrombus) was caught in a PFO (Panel C-E, Videos S2-3). A second smaller mass/thrombus was seen on the Eustachian valve near the right atrial/inferior vena cava junction (Panel F, Video S4). CAG confirmed a 100% occluded distal right posterolateral artery suggestive of an embolic phenomenon. The patient underwent successful thrombectomy, retrieving a large thrombus burden (Panel G, Videos S5-7). CT angiography showed occluded internal carotid artery (Panel H). Pathology from thrombectomy confirmed fibrin-rich thrombus. The patient had bilateral lower extremity deep vein thrombosis and bilateral diffuse pulmonary embolisms.