Myocardial and cerebral infarction in a young female patient with intrapulmonary shunt

Abstract-Text (inkl. Referenzen und Bildunterschriften)

A 42 year-old woman presented in the emergency department of Karolinska University Hospital of Stockholm after prehospital performed CPR including the administration of an electric shock (AED). There is no history of cardiovascular disease. Cardiac risk factors included immobility (b.c. of the longer car ride to Stockholm), abuse of nicotine and being on birth control (oral contraceptive). Physical examination revealed no signs of vein thrombosis. Incidentally she was infected with COVID-19.

Because of ST-Deviations in electrocardiogramm and an elevated troponin a coronar angiography was performed. There were no signs of arteriosclerosis but indication of SCAD of RMS 2. Cerebral imaging revealed multiple small embolism cortical and subcortical. In stable conditions the patient was finally transfered to our cardiology department for further investigation and therapy.

TTE showed normal values. To further evaluate a possible PFO/ASD contrast agent (Gelafusal) was administered through the left cubital vein and revealed a relevant right-to-left shunt with a stream through LUPV (left upper pulmonary vein) (Img.2). In the subsequently performed TEE the diagnosis of right-to-left-shunt on pulmonary-level was confirmed whereas there was no evidence for PFO (Img. 4.). Unfortunately a performed MR-Imaging could not show the exact localisation of the shunt.

In conclusion smallest embolism from the venous circulation were probably brought to peripheral arteries through the right-to-left shunt and induced myocardial infarction with ventricular tachycardia (VT) and cortical embolism as shown in cMRI.

We induced a medication with DOAC (Lixiana). Furthermore a cardiac event recorder (REVEAL LINQ) was implanted. Thrombophilia-testing was performed 6 weeks after the event showing no abnormal results.