When a Hole in the Heart Sends Clots the Wrong Way

Simultaneous presentation of ST-elevation myocardial infarction (STEMI) and pulmonary embolism (PE) is rare and should prompt consideration of paradoxical embolism (PDE) through a patent foramen ovale (PFO). We report the case of a 48-year-old lifelong athlete presenting with sudden cardiac arrest due to acute inferior STEMI, without angiographic evidence of atherosclerotic disease. Initial computed tomography angiography revealed bilateral pulmonary emboli. Coronary angiography demonstrated thrombotic occlusion of the mid-right coronary artery, successfully treated with mechanical thrombectomy, revealing normal coronaries. Subsequent echocardiography confirmed a PFO with right-to-left shunting. The patient was stabilized on anticoagulation and later underwent successful percutaneous PFO closure. Three-year follow-up showed no recurrence. This case underscores the importance of considering PDE in patients with acute coronary occlusion and concurrent PE or systemic emboli, particularly in the absence of atherosclerosis. Early recognition and targeted intervention, including PFO closure, can prevent recurrence and improve outcomes.