A rare case of paradoxical embolism causing myocardial infarction: Successfully aborted by aspiration alone

Summary A 58-year-old male presented with severe substernal chest pain along with bilateral lower extremity pain. He was tachycardic, tachypneic, and hypoxic with tender right calf. Electrocardiogram showed ST elevation in anterior-lateral leads. Emergency coronary angiography revealed widely patent proximal left anterior descending (LAD) artery and total distal occlusion with an abrupt cut-off. The remaining coronary arteries did not have significant disease. An Export aspiration catheter was used and thrombus was aspirated from the LAD with return of TIMI flow grade 3 and normalization of the ST elevations. Doppler ultrasound revealed deep vein thrombosis; transthoracic echocardiogram using agitated saline echocontrast showed a patent foramen ovale. Nearly 5% of patients with ST elevation myocardial infarction do not have demonstrable atherosclerosis by coronary angiography; paradoxical coronary embolism is among the leading causes in such cases. Paradoxical embolism to the coronary tree is under diagnosed and its antemortem diagnosis is difficult. Information regarding appropriate management of myocardial infarction due to coronary embolism is scant. Aspiration of intracoronary thrombus provides good clinical results, avoiding clot fragmentation and balloon injury associated with angioplasty. We present a rare case of antemortem diagnosis of paradoxical embolism to the coronary artery successfully treated with aspiration alone.