Introduction: Atherosclerosis is the most common etiology of myocardial infarction (MI), yet rarely, MI may be caused by an embolus to one of the epicardial arteries.

Case: A 66-year old female, with very few risk factors for coronary artery disease, presented clinically at Emergency Department with vomiting and ventricular fibrillation on cardiac monitor. After successful resuscitation, she was noted to have ST-elevation in the anterior and inferior walls of the heart. Cardiac catheterization showed total occlusion of the mid-left anterior descending artery with the rest of the coronary tree normal. Percutaneous coronary intervention was done however patient had no-reflow phenomenon, indicating that perfusion to the affected myocardium was still compromised . Follow-up examination upon admission at the coronary care unit showed new onset grade 3/6 holosystolic murmur at the left sternal border. Her 2D echo showed abnormal color flow across the muscular ventricular septum, indicative of ventricular septal rupture. There was also note of calcifications in the aortic valve and calcified plaques along the walls of the aortic root, which were possibly the source of the coronary embolus. Serial monitoring of the ST elevation was then done and these showed resolution of the ST changes. Patient was also hemodynamically stable despite not undergoing intervention for the ventricular septal rupture because of financial constraints. She remained stable for the rest of her hospital stay and was eventually discharged and advised to consult with a cardiologist upon her return to her home country for definitive repair of ventricular septal rupture.

Conclusion: Coronary artery embolism should always be a consideration for patients who developed myocardial infarction in the setting of an angiographically normal coronary arteries.

Keywords: coronary embolism, myocardial infarction, ventricular septal rupture

1. Sial, JA, Ferman, MT, Saghir, T, and Rasool, SI. Coronary embolism causing acute myocardial infarction in a patient with mitral valve prosthesis: successful management with angioplasty. J Pak Med Assoc. 59(6): 409-10, 2009.
2. Chandrasekaran, B and Kurbaan, AS. Myocardial infarction with angiographically normal coronary arteries. J R Soc Med. 95: 398-400, 2002.
3. Widimsky, P, Stellova, B, Groch, L, Aschermann, M, Branny, M, Zelizko, M, Stasek,J, and Fomanek, P. Prevalence of normal coronary angiography in the acute phase of ST elevation myocardial infarction: Experience from PRAGUE studies. Can J Cardiol. 22(13): 1147-52, 2006.
4. Nakazone, M, Tavares, B, Machado, M, and Maia, L. Acute myocardial infarction due to coronary artery embolism in a patient with mechanical aortic valve prosthesis. Case Reports in Medicine. Article ID 751857, 4 pages. doi:10.1155/2010/751857, 2010.
5. Camaro, C and Aengevaeren, WRM. Acute myocardial infarction due to coronary artery embolism in a patient with atrial fibrillation. Neth Heart J. 17: 279-9, 2009.
6. Murthy, A, Shea, M, Karnati, P and El-Hajjar, M. A rare case of paradoxical embolism causing myocardial infarction: successfully aborted by aspiration alone. Journal of Cardiology. 54: 503-6, 2009.
7. Kirubakaran, S, Zuberi, Z and Gill, J. Acute myocardial infarction due to a coronary embolus during left atrial ablation for persistent atrial fibrillation. Europace. 2012.
8. Schmermund, A and Ebel, R. Unstable coronary plaque and its relation to coronary calcium. Circulation. 104: 1682-1687, 2001.
9. Greenland, P and Bonow R. How low-risk is a coronary calcium score of zero?: The importance of conditional probability. Circulation. 117: 1627-1629, 2008.
10. Suzuki, M, Enomoto, D, Seike, F, Fujita, S and Honda, K. Clinical features of early myocardial rupture of acute myocardial infarction. Angiology. 63(6): 453-56, 2012.