A middle-aged woman with a history of completed myocardial infarction and left-sided paresthesias presented with chest pain and elevated troponin T levels (1037 ng/L; normal levels, ⟨14 ng/L).
Coronary angiography demonstrated unobstructed coronary arteries; cardiac magnetic resonance imaging suggested edema from acute infarction at the site of a previous infarction; and a transthoracic echocardiogram saline contrast study (ie, bubble study) demonstrated color flow at rest across the interatrial septum and, as seen in this video, a large shunt on Valsalva maneuver consistent with a grade 3 patent foramen ovale (PFO). Brain magnetic resonance imaging revealed bilateral white matter lesions thought to be secondary to small vessel disease greater in number than expected for the patient's age, raising suspicion for microemboli.
She was diagnosed with paradoxical embolism (blood clot traveling from the right venous to the left arterial side) through a PFO causing recurrent systemic embolism and was treated with PFO closure and 6 months of antiplatelet therapy.
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