Paradoxical Coronary Embolism Through a Patent Foramen Ovale Presenting as ST Elevation Myocardial Infarction With Distal Right Coronary Artery Occlusion

We report the case of a 57-year-old man presenting with inferior ST elevation myocardial infarction. Initial electrocardiography demonstrated ST segment elevation in the inferior leads. After administration of aspirin and intravenous heparin, repeat electrocardiography showed partial improvement in ST segment elevation. Emergent coronary angiography revealed abrupt distal occlusion of branches of a dominant right coronary artery (RCA) with preserved proximal flow. Intravascular ultrasound (IVUS) demonstrated minimal coronary atherosclerosis without plaque rupture or dissection. Transthoracic and transesophageal echocardiography (TEE) demonstrated a patent foramen ovale with atrial septal aneurysm and right-to-left shunting. Hypercoagulable evaluation was unremarkable. Follow-up echocardiography identified a small left ventricular apical thrombus.