A middle-aged woman presented with chest pain, elevated troponin-T of 1037 ng/L (normal <14 ng/L; to convert to micrograms per liter, multiply by 1), and anterior T-wave inversion on electrocardiography. She was a smoker with hypertension and kidney dysfunction, with a history of left-sided paresthesia.
Coronary angiography demonstrated unobstructed coronary arteries. Cardiovascular magnetic resonance (CMR) imaging revealed subendocardial midinferolateral late gadolinium enhancement with corresponding hypokinesis consistent with a partial-thickness myocardial infarction. Prolonged Holter monitoring showed no evidence of atrial fibrillation.
Two years later, she had a similar presentation consistent with a non–ST-elevation myocardial infarction. Repeated coronary angiography again demonstrated unobstructed coronary arteries. The CMR revealed the same midinferolateral late gadolinium enhancement as at the initial examination (Figure, A) but with focal enhancement on T2 short tau inversion recovery sequences (Figure, B), with increased T1 and T2 values suggestive of associated edema from an acute infarction in the same territory. A mobile interatrial septum was noted on 4-chamber cine imaging. A transthoracic echocardiogram bubble study demonstrated color flow at rest across the interatrial septum and a large shunt on Valsalva maneuver consistent with a grade 3 patent foramen ovale (PFO) (Video). Coincidentally, a brain MR scan to investigate the recurrent paresthesia revealed bilateral white matter lesions thought to be secondary to small-vessel disease greater in number than expected for the patient’s age, raising suspicion for microemboli.