paroxysmal nocturnal dyspnea. Initial vitals showed an afebrile, hemodynamically stable patient. Labs revealed mild hypokalemia, hypomagnesemia, elevated high-sensitivity troponin of 12 ng/mL, and a BNP of 235 ng/L (baseline). Cardiac monitoring and an electrocardiogram showed monomorphic VT with heart rates in the 180-210 bpm range, requiring anti-tachycardia pacing (ATP) and three episodes of shock at 35 joules. She was started on amiodarone bolus and infusion, metoprolol tartrate, and dual antiplatelet therapy. Myocardial viability study revealed no viable myocardium in the left circumflex (LCx) territory. An echocardiogram showed a decreased EF of 20-25%, apical left ventricular aneurysm, and reduced wall motion. A Electrophysiology consult attributed the VT to ischemia. She underwent left heart catheterization, revealing complete total occlusion of the proximal
left anterior descending (LAD) artery with established collaterals and 70% stenosis of the ostial lateral LCx. Successful placement of a drug-eluting stent from the left main to the LCx prevented further VT episodes. She was discharged on dual antiplatelet
therapy, amiodarone taper, and restarted on guideline-directed medical therapy (GDMT).
Discussion: This case illustrates the multifaceted approach to treating a VT storm. Ablation is the first-line therapy, but LCx revascularization was prioritized to prevent scarring that could worsen the condition. While revascularization does not directly treat the storm, it reduces mortality. Managing the storm involved initiating antiarrhythmic therapy, revascularization, and optimizing GDMT to minimize mortality, rehospitalization, and adverse outcomes.
PARADOXICAL EMBOLISM TO THE CORONARY ARTERIES: AN UNCOMMON CAUSE OF ACUTE MYOCARDIAL INFARCTION Swesha Shrestha, Shekhar Gurung MD, Nisheem Pokharel MD, Thomas R Smith MD; St Francis Medical Center, Monroe, LA.
Introduction: Coronary embolism accounts for approximately 3% of cases of myocardial infarction with no coronary atherosclerosis (MINOCA), often linked to conditions like atrial fibrillation and infective endocarditis. Even less commonly, this can happen via paradoxical embolism in the setting of a patent foramen ovale (PFO). The coronary artery anatomy, with its right-angle departure from the aortic root and partial covering by aortic valve cusps, and its size disparity from the aorta with diastolic filling make this condition rare. Case: A 48-year-old male with no significant medical history presented with unrelieved dull aching central chest pain. He had a BMI of 24 and did not smoke or drink alcohol. Workup revealed a significantly elevated troponin I level of 4.53 ng/mL, up trending to 13.56 ng/mL. An EKG demonstrated sinus bradycardia without ST-segment changes. Emergent coronary angiography revealed no significant atherosclerotic disease. However, there was a notable thrombus in the distal segment of a small-caliber diagonal branch with faint distal flow. The vessel was deemed too small and distal to be intervened on or evaluated with an intravascular ultrasound.
Given the concern for a cardioembolic event, heparin was initiated. A transthoracic echocardiogram demonstrated a structurally normal heart with a normal ejection fraction. A transesophageal echocardiogram with bubble study confirmed the presence of a PFO. Symptoms subsided in less than 24 hours, and he was discharged in stable condition on apixaban, clopidogrel, and atorvastatin with plans for PFO closure and a loop recorder placement. No arrhythmia was detected during his hospital stay. Discussion: While paradoxical coronary embolism via PFO remains a rare cause of myocardial ischemia, it must be considered in patients without atherosclerosis or other traditional cardiovascular risk factors. It is important to understand the etiology as the management of embolic myocardial
ischemia requires additional considerations to prevent recurrence and improve patient
outcomes. Management involves a combination of anticoagulation and antiplatelet therapy to prevent further thromboembolic events, along with monitoring for occult arrhythmia. Consideration of PFO closure is also warranted, and decisions are individualized based on the patient’s risk profile. 11
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