Paradoxical Coronary Artery Embolism via Patent Foramen Ovale in Acute Myocardial Infarction: A Narrative Mini Review of the Cardio-Neurological Interface
Eustaquio Maria Onorato1*, Gian Paolo Anzola2, Francesco Casilli3, Antonio Luca Bartorelli1,4
1University Cardiology Department, Ospedale Galeazzi-Sant’Ambrogio, Milan, Italy
2Consultant, Neurologist/Neurosonologist, Villa Barbarano Clinic, Salò, Italy
3Cardiology Department and Coronary Care Unit (CCU), Ospedale Galeazzi-Sant’Ambrogio, Milan, Italy
4Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
Background: Paradoxical coronary artery embolism (PCAE) via a Patent Foramen Ovale (PFO) with a Right-to-Left Shunt (RLS) is an underrecognized cause of myocardial infarction with nonobstructive coronary arteries (MINOCA). Because it is a systemic embolic process, PCAE is frequently associated with cryptogenic neurological events. This review synthesizes current evidence to provide an operational diagnostic framework linking neurovascular and cardioembolic pathways.
Methods: A comprehensive, reproducible literature search of PubMed/MEDLINE was performed from January 2000 through June 2026 using validated Medical Subject Headings (MeSH) and precisely nested Boolean text strings to capture the intersection of paradoxical embolism, interatrial shunts, and myocardial infarction. Given the scarcity of large clinical trials, the eligibility criteria were expanded to include case series and individual case reports.
Key Findings: Diagnosing PCAE requires sequential multi-modality evaluations: invasive angiography to document nonobstructive disease, intracoronary imaging (Optical Coherence Tomography [OCT] or Intravascular Ultrasound [IVUS]) to exclude plaque dynamics, cardiac magnetic resonance imaging (CMRI) to confirm ischemic tissue distribution, and contrast-enhanced shunt evaluations via transesophageal echocardiography (c-TEE) or transcranial Doppler (c-TCD). Management requires balancing acute antiplatelet therapy with individualized, long-term secondary anticoagulation or structural PFO device closure.
Conclusions: Because recommendations for PFO closure in coronary presentations are largely extrapolated from ischemic stroke guidelines and expert consensus, close coordination within a dedicated multidisciplinary Heart-Brain Team is essential to optimize patient selection and prevent recurrent systemic embolic events across multiple vascular territories.
DOI: 10.29245/2572.942X/2026/2.1333 View / Download Pdf