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paradoxical embolism causing acute myocardial infarction ( ami ) in the setting of patent foramen ovale ( pfo ) or atrial septal defect ( asd ) has been rarely reported.[14 ] the present report describes a case of ami due to paradoxical embolism in a patient with asd .
this may be related to the presence of intracardiac right to left shunt in the context of hypercoagulable state .
the presentation also emphasizes the importance of adequate anticoagulation therapy during perioperative period in patients with pfo / asd and hypercoagulable state .
a 16-year - old male known to have congenital heart disease was admitted with dyspnea on exertion ( new york heart association class ii ) . at 5 months of age
, he was diagnosed to have pulmonary stenosis , hypoplastic right ventricle , and asd .
the peak gradient across pulmonary valve dropped from 100 to 20 mmhg . on examination ,
electrocardiogram ( ecg ) showed a sinus rhythm and right bundle branch block [ figure 1a ] .
echocardiography showed mild pulmonary stenosis , severe right ventricular hypertrophy , and asd with right to left atrial shunt [ figure 2 ] .
( a ) a baseline electrocardiogram that showed sinus rhythm and right bundle branch block , ( b ) electrocardiogram immediately after cardiac arrest showed st segment elevation in the inferior leads and multiple premature atrial beats an echocardiography that demonstrated atrial septal defect ( upper ) , right to left shunt ( arrow ) and small severely hypertrophied right ventricle ( lower ) because of persistent symptoms , cyanosis , and right to left atrial shunt , the patient underwent glenn operation and partial closure of the asd .
two weeks after surgery , while using the incentive spirometry , the patient suddenly collapsed , developed ventricular fibrillation , and required two direct current ( dc ) shocks .
the patient was taken to catheterization laboratory where a total occlusion of the left circumflex coronary artery was treated with thrombus aspiration using export catheter ( medtronic , minneapolis , mn , usa ) .
the coronary flow was restored at timi flow 3 [ figure 3 ] with no further stenting .
the patient was then maintained on glycoprotein iib / iiia inhibitor ( abciximab ) and heparin infusions for 12 hours .
few months later , he underwent elective device closure of the asd / pfo [ figure 4 ] that resulted in substantial improvement in his symptoms .
( a ) invasive coronary angiography that demonstrated total occlusion of the left circumflex coronary artery with filling defect suggestive of thrombus , ( b ) the timi 3 flow was restored after repeated aspirations of the thrombus ( a ) , an echocardiography that demonstrated atrial septal defect with right to left shunt , ( b ) three dimensional echocardiography during device deployment ( c and d ) echocardiography few days after device deployment where atrial septal device was in place with no residual shunt
paradoxical embolism due to a pfo or an asd resulting in ami has been reported in the literature[16 ] but is rarely considered in clinical practice . coronary embolism
should always be suspected in the context of sudden chest pain in patients with valvular prosthesis , chronic atrial fibrillation , dilated cardiomyopathy , infective endocarditis , intracardiac shunts , cardiac myxoma , mural thrombi , and hypercoagulable states.[710 ] the standard treatment for coronary embolism with st elevation ami remains uncertain .
however , thrombolysis , percutaneous transluminal coronary angioplasty , and thrombus aspiration have been frequently used.[1113 ] thrombolysis has been associated with distal embolization causing complete obstruction in smaller branches.[1214 ] furthermore , if the source of the embolus is infected vegetation , thrombolysis might be contraindicated .
percutaneous transluminal coronary angioplasty and stenting have been used in some cases with coronary embolism and consequent ami .
successful catheter aspiration embolectomy has been described by some authors . in our patient with recent surgery
catheter aspiration embolectomy for the intracoronary thrombus was found very effective precluding the need for stenting .
anticoagulation with heparin and intravenous glycoprotein iib / iiia inhibitors was also used to reduce the risk of further embolism .
we present a case of a young male with severe pulmonary stenosis , hypoplastic right ventricle , and atrial septal defect . 
 acute embolic myocardial infarction , followed by cardiac arrest , occurred during hospitalization after glenn operation . 
 the therapeutic challenges are discussed . 
 insufficient anticoagulation therapy during the postoperative period was a possible contributing factor leading to embolic myocardial infarction .