case_images: PMC11272397_01
case_images: (a) Initial EKG done in the emergency department showed normal sinus rhythm; an old right bundle branch block (outlined with red box); mild ST depressions (< 1 mm) in leads I, aVL (denoted with red arrows in aVL); T-inversions in II, V4-5 (denoted with black arrows in V4); and ST elevation in III, aVF (< 1 mm) (denoted with red circles in lead III). (b) EKG done 25 min later shows similar findings, but sinus bradycardia.
case_images: CRIPU2024-6725308.001.jpg
case_images: PMC11272397_01_CRIPU2024-6725308.001.jpg
case_images: fig1
case_images: A 12-lead electrocardiogram (EKG) performed in the ED did not reveal any clear acute process and was similar to prior EKGs from previous admissions (Figure 1).
case_images: Left heart catheterization images depict a blockage in the distal right coronary artery. Each image shows the blockage from a left anterior oblique (LAO) view with (a) cranial angulation and (b) caudal angulation. For both (a) and (b), the white arrow points to the vessel blockage. R1 = proximal right coronary artery; R2 = middle right coronary artery; R3 = distal right coronary artery; RPDA = right posterior descending artery.
case_images: CRIPU2024-6725308.002.jpg
case_images: PMC11272397_01_CRIPU2024-6725308.002.jpg
case_images: fig2
case_images: Given the remarkably elevated troponin T levels and symptomatic chest pain, she underwent repeat left heart catheterization (Figure 2).
case_images: Transesophageal echocardiography revealing the patent foramen ovale (PFO). (a, b) The PFO (white arrow) in different views. (b) The leakage of saline contrast across the atria. (c, d) The shunting/mixing of blood through the PFO.
case_images: CRIPU2024-6725308.003.jpg
case_images: PMC11272397_01_CRIPU2024-6725308.003.jpg
case_images: fig3
case_images: The transesophageal echocardiogram (TEE) with color flow Doppler and intravenous saline contrast revealed a right-to-left shunt through a PFO, along with an aneurysmal interatrial septum (Figure 3).
case_images: Cardiac MRI revealing the patent foramen ovale (PFO). (a, b) The PFO (white arrow) and interatrial aneurysm. (c, d) The dilated main pulmonary artery. In (d), the blue line denotes the main pulmonary artery (5.30 cm), and the yellow line denotes the left pulmonary artery (2.80 cm). LA, left atrium; LV, left ventricle; RA, right atrium; RV, right ventricle.
case_images: CRIPU2024-6725308.004.jpg
case_images: PMC11272397_01_CRIPU2024-6725308.004.jpg
case_images: fig4
case_images: A cardiac magnetic resonance imaging (MRI) scan confirmed the presence of an atrial septal aneurysm, which is defined as a rare cardiac deformity where the septum bulges into one side of the atria, along with a PFO (Figure 4).