International Journal of Clinical & Medical Images

A 46-year-old man with remote anterolateral MI (complicated by VT storm requiring ICD) presented in bi-ventricular heart failure with peripheral eosinophilia and cardiogenic shock. Mechanical ventilation worsened hypoxemia, despite FiO2 of 1.0 and nitric oxide. TTE demonstrated LVEF of 20%, PFO (right-to-left-shunting) and sub-pulmonic RVOTO (Figure 1A, Videos 1 and 2) resulting in additional obstructive shock. The PFO functioned as a RV-vent; percutaneous closure was not performed. TEE showed echogenic material layering the RV, TV, RV lead and sub-pulmonic-valve napkin-ring-lesion causing RVOTO (Figure 1B
and Video 3). Cardiac-MRI demonstrated delayed enhancement (Figure 1C and 1D). Endomyocardial and subsequent surgical biopsies were non-diagnostic. Surgical PFO closure, TV repair, debulking of RV and sub-pulmonic-lesions, and ICD removal were performed. Steroids were discontinued as peripheral eosinophilia had improved prior to initiation. The patient recovered, was discharged home and remains stable. This case demonstrates a PFO functioning as a RV-vent. Closure of the PFO without relieving the RVOTO would have proven
deleterious.