Abstract 15696: Simultaneous Presentation of ST-Elevation Myocardial Infarction, Ischemic Stroke, and Pulmonary Embolism in a Patient With Thrombus-in-Transit Across a Patent Foramen Ovale

Case Description: A 70-year-old woman with a history of hypertension, hypothyroidism, and sigmoid colectomy, presented to the ER with altered mental status, slurred speech, and left-sided weakness. She was hemodynamically stable, and exam was notable for dysarthria, left-sided facial droop, and left-sided upper and lower extremity weakness. ECG showed ST-elevation in leads I, aVL, and V1-V3, and ST-depression in II, III, and aVF. CT Head was without intracranial hemorrhage. Emergency coronary angiography showed subtotal thrombotic occlusion of the left main, LAD, and LCX arteries consistent with embolic etiology. Coronary thrombectomy re-established TIMI 3 flow. The patient then underwent CTA of the head and neck, which visualized both right anterior M2 occlusion and large pulmonary emboli in the right and left main PAs. She underwent emergency mechanical thrombectomy of the right MCA. With induction of anesthesia she suffered PEA arrest, for which she received 5 minutes of CPR and epinephrine and ROSC was obtained. She then underwent successful thrombectomy of the right anterior M2. Patient then underwent bilateral pulmonary thrombectomy and IVC filter placement. Over the ensuing 24 hours she weaned from pressors, was extubated, and was alert with only mild left hemiparesis. Bilateral lower extremity venous dopplers were negative for DVT, and an echocardiogram showed a serpiginous echodensity in both atria and across the intra-atrial septum, consistent with a large thrombus-in-transit through a PFO. CT Surgery was consulted, and patient underwent successful bi-atrial thrombectomy with PFO closure.

Discussion: Simultaneous thromboembolic MI, stroke and PE is an exceedingly rare and catastrophic clinical presentation. Initial management should involve a promptly-assembled multidisciplinary team to determine if the patient is a candidate for procedural or operative intervention, and, if so, to determine the order in which they should be completed. Subsequently, a workup should be initiated to determine an underlying cause of the presentation, including appropriate thrombophilia workup and imaging. If feasible, surgical thrombectomy and PFO closure may be indicated to prevent further embolic phenomena.