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CardioNerds\xa0(Amit Goyal\xa0&\xa0Dan Ambinder) join Lankenau Medical Center cardiology fellows (Gwen McNeill and Shaung Ooi) for some Philly cheesesteaks! They discuss a fascinating case of Embolic Acute Coronary Syndrome from PFO and Pulmonary Hypertension. Dr. John Clark provides the E-CPR and program director Dr. Jeanine Romanelli provides a message for applicants. Episode notes were developed by Johns Hopkins internal medicine resident\xa0Tommy Das\xa0with mentorship from University of Maryland cardiology fellow\xa0Karan Desai.\xa0\n\n\n\n\n\nJump to: Patient summary - Case figures & media - Case teaching - Educational video - References - Production team\n\n\n\nEpisode graphic by\xa0Dr. Carine Hamo\n\n\n\n\n\n\n\nThe\xa0CardioNerds Cardiology Case Reports\xa0series shines light on the hidden curriculum of medical storytelling. We learn together while discussing fascinating cases in this fun, engaging, and educational format. Each episode ends with an\xa0\u201cExpert CardioNerd Perspectives & Review\u201d (E-CPR)\xa0for a nuanced teaching from a content expert. We truly believe that hearing about a patient is the singular theme that unifies everyone at every level, from the student to the professor emeritus.\n\n\n\nWe are teaming up with the\xa0ACC FIT Section\xa0to use the\xa0#CNCR episodes\xa0to showcase CV education across the country in the era of virtual recruitment. As part of the recruitment series, each episode features fellows from a given program discussing and teaching about an interesting case as well as sharing what makes their hearts flutter about their fellowship training. The case discussion is followed by both an\xa0E-CPR\xa0segment and a message from the program director.\n\n\n\nCardioNerds Case Reports PageCardioNerds Episode PageCardioNerds AcademySubscribe to our newsletter- The HeartbeatSupport our educational mission by becoming a Patron!Cardiology Programs Twitter Group created by Dr. Nosheen Reza\n\n\n\n\n\n\n\n\n\n\n\nPatient Summary\n\n\n\nA woman in her early 40s\xa0with history of tobacco\xa0and prior methamphetamine use presented with acute onset\xa0chest pain. She was found to have an elevated troponin, anterior T wave inversions, and apical akinesis on TTE. Coronary angiography\xa0showed a coronary embolism in the mid-distal LAD. Attempts to wire the lesion led to distal embolization of the clot, and IVUS showed no underlying arteriosclerosis.\xa0\xa0\n\n\n\nTo investigate the etiology of the coronary embolus, a repeat TTE with\xa0agitated saline\xa0was done that suggested a PFO with\xa0right to left flow, as well as decreased RV function with an estimated RVSP of 70 mmHg.\xa0The clinical picture was that of a paradoxical coronary embolus, arising from the right (venous) side traveling to the left (arterial) side via a PFO.\xa0PFO closure was discussed but not performed given severe pulmonary hypertension with Right to Left shunt. In this circumstance, the PFO functions as a "pop-off valve" for the overloaded RV; closing it risks precipitating acute RV overload and failure.\xa0A RHC showed\xa0a PA pressure of 70/24 mmHg with\xa0mPAP\xa0of 40 mmHg, PCWP 5 mmHg, and PVR of 11 woods units.\xa0Given\xa0concern for idiopathic PH, a vasodilator challenge was done\xa0which did not show reactivity, and she was started on\xa0ambrisentan\xa0and sildenafil. Ultimately, the etiology of her pulmonary hypertension was felt to be due to PAH from prior methamphetamine use vs. idiopathic PAH. On follow-up, her PA pressures and RV function had greatly approved, allowing for\xa0safe and successful PFO closure in an attempt to prevent future emboli.\u202f\xa0Final diagnosis: Embolic Acute Coronary Syndrome from PFO & Pulmonary Hypertension. \n\n\n\n\n\n\n\n\nCase Media\n\n\n\n\n\n\nBefore treatment: short axisBefore treatment: apical 4Before treatment: RVSPAfter treatment: Short axisAfter treatment: Apical 4After treatment: RVSPClick to enlarge ???\n\n\n\n\n\n\nhttps://youtu.be/XpnJKZuNVrM\n1. Coronary angio of embolism2. PFO on TEE with R to L shunt by Doppler3. TTE bubble after PFO closure\n\n\n\n\n\n\n\n\n\nEpisode Schematics & Teaching\n\n\n\nClick to enlarge ???\n\n\n\n\n\n\n\nThe CardioNerds 5!