Triple nightmare: ST-elevation myocardial infarction, acute ischemic stroke and pulmonary embolism simultaneously occuring in a patient with a large patent foramen ovale: Case reports

BACKGROUND:
ST-elevation myocardial infarction (STE-ACS) , ischemic stroke (IS), and acute pulmonary embolism (PE) are life-threatening conditions. The simultaneous occurrence of all three  is very rare and requires thorough etiological investigation. Patent foramen ovale (PFO) should always be considered as an origin of paradoxical embolism . We present a case of a patient with STE-ACS, PE and IS occuring simultaneously, which managed with initial emergency percutaneous coronary intervention (PCI), insertion of a cerebral protection system to prevent from further cerebral embolism and surgical embolectomy.

CASE DESCRIPTION:
A 45-year-old male presented with acute chest pain at our emergency room. ECG revealed infero-lateral STE-ACS (Fig 1/, ECG). The patient underwent emergency cardiac catheterization showing complete occlusion of the circumflex artery (Fig 7). Reperfusion and drug-eluting-stent-implantation were performed. By applying thrombus aspiration & platelet aggregation inhibation using intravenously administered nonpeptide glycoprotein IIb/IIIa receptor antagonist, revascularization was achieved with good angiographic result and with TIMI III flow (Fig 10). However, severe dyspnea persisted after revascularization requiring high doses of oxygen. Intraprocedural transthoracic echocardiography showed severe right ventricular  dysfunction with D-sigh and a suspected thrombus in the left atrium (LA)(Fig 3/4). Pulmonary CT-scan was performed immediately and showed bilateral central PE (Fig 11). Besides, neurological abnormalities occurred and a cranial CT scan owed cerebral IS with complete occlusion of the left internal carotid artery (Fig.12). We applied a cerebral protection into the right brachiocephalic trunk (Fig 13). A transoesphagial echocardiography revealed massive thrombus burden in LA and the mitral valve(Fig 4/5). A PFO (Fig 5) was diagnosed as the obvious cause. Due to the huge thrombus in the LA with the risk of further embolization, we transferred the patient to cardiac surgery for emergency surgical embolectomy from the LA and bilateral pulmonary embolectomy.  The patient underwent emergent cardiac surgery through a median sternotomy with the use of extracorporeal circulation in deep hypothermia (30–32℃). In addition to the thrombectomy from the LA and pulmonary artery (Fig 14), surgical PFO closure and LA-appendage resection were performed. The patient received initial therapeutic doses of heparin and subsequent oral anticoagulation with Marcumar, Clopidogrel and Aspirin (for 4 weeks). The patient was discharged to the rehabilitation clinic 3 weeks after admission in good general condition. No residual thrombus was detected in ultrasound. A comprehensive coagulation diagnostic is planned as the family history is very suspicious in this regard.

CONCLUSION:
Paradoxical embolies remain a challenging situation in daily clinical practice. This simultaneous occurrence of AMI, IS, and PE is rare. All three challenging diagnoses necessitating immediate medical and surgical intervention. The handling of such a multifaceted scenario is not well researched. Despite significant clinical needs, there are no evidence-based guidelines available for managing the co-occurrence of these conditions. Additional research is required to enhance the outcomes for patients experiencing this rare convergence of conditions. Our case highlights that interdisciplinary work ( heart team) is required to ensure effective patient care and survival.