Paradoxical Coronary Artery Embolism Through a Patent Foramen Ovale in a Young Adult

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

You say that coronary artery embolism can occur under "favorable hemodynamic conditions". I would like you to describe what those conditions might be. Also, decription of an isolated TWI in lead III is not relevant and should be removed.

Author Response

please see the attachment

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

Authors present a clinically relevant and well-documented case of paradoxical coronary embolism through a patent foramen ovale (PFO) in a young patient. The topic is important, given the rarity and potential under-recognition of coronary embolism as a cause of myocardial infarction in patients without atherosclerotic disease. The use of multimodality imaging (angiography, IVUS, TTE, TEE) is an important part of making the right diagnosis and adequate treatment.

The authors described the large PFO with bidirectional shunting, but I would say that the definitive proof of paradoxical embolism is lacking. No thrombus was identified in the venous system, and the hypercoagulability test workup was negative. So, this diagnosis is presumptive but highly likely. Namely, we need prolonged rhythm monitoring (for paroxysmal atrial fibrillation) and a more thorough examination regarding thrombophilia. This should be mentioned in the manuscript. Is there a family history of thrombophilia, PTE/DVT, cardiac disease, SCAD, etc.?

Add a section on the differential diagnosis, including SCAD, MINOCA, and coronary vasospasm.

Please explain why coronary embolism is less common than cerebral embolism (mechanistically).

Please correct the figure legends.

Author Response

see attachment 

Author Response File: Author Response.pdf

Reviewer 3 Report

Comments and Suggestions for Authors

This manuscript presents a clinically interesting and educational case of suspected paradoxical coronary embolism in a young adult with a patent foramen ovale (PFO). The integration of multimodality imaging (angiography, IVUS, TTE, and TEE) is a clear strength and enhances the diagnostic narrative.
However, from a methodological standpoint as a case report, the manuscript falls short in several key areas required for high-quality case reporting (CARE guidelines) and causal attribution rigor. The central claim—paradoxical coronary embolism—is plausible but not definitively demonstrated, and the report currently overstates causal certainty relative to the available evidence.
I would recommend major revision before consideration for publication. Please find below my comments:

-Lack of Robust Causal Inference Framework
The manuscript asserts paradoxical embolism as the most likely mechanism, but this conclusion is inferential rather than demonstrated.
Key missing elements:
No direct evidence of venous thrombus
Lower-extremity Doppler was negative
No pelvic/IVC imaging or extended venous evaluation performed
No embolus capture or histopathological confirmation
No temporal trigger for right-to-left shunting
No Valsalva, cough, or hemodynamic event documented

The report demonstrates coronary occlusion, absence of atherosclerosis and presence of PFO.
But fails to demonstrate the embolic pathway itself.

Recommendation:
Reframe the diagnosis as:
“probable paradoxical coronary embolism” rather than definitive.

-Incomplete Differential Diagnosis
The manuscript does not adequately exclude alternative causes of MINOCA (Myocardial Infarction with Non-Obstructive Coronary Arteries / non-atherothrombotic MI), including:
Coronary vasospasm
Coronary microembolism from occult sources
Spontaneous coronary artery thrombosis
Hypercoagulable transient states (not fully explored)
Drug-induced ischemia (e.g., cocaine—self-reported only)

Although IVUS excluded plaque rupture , this does not exclude all causes of thrombosis.

Recommendation:
Include a structured differential diagnosis section, explicitly addressing:
Why vasospasm is unlikely
Why in situ thrombosis is unlikely
Why other embolic sources were excluded

-Hypercoagulable Workup
The manuscript states that testing was “unrevealing” , but:
No complete panel description
No timing of testing (acute vs convalescent phase)
No repeat testing
No mention of Factor V Leiden, Prothrombin mutation,Lupus anticoagulant timing or D-dimer

This is insufficient for a claim of “extensive evaluation.”

Recommendation:
Please provide:
Full list of tests
Timing relative to acute event
Interpretation limitations

-Missing Timeline (CARE Guideline Violation)
A structured timeline is absent, which is a core requirement of high-quality case reports.

Missing:
Symptom onset → ED presentation
Biomarker progression
Imaging sequence
Intervention timing
Follow-up duration

Recommendation:
Add a chronological timeline figure or table, which is essential for reproducibility and clinical interpretability.

-Insufficient Follow-Up Data
The manuscript states the patient “remained asymptomatic” after PFO closure , but:
No duration specified
No imaging follow-up
No recurrence assessment
No medication adherence details

Recommendation:
Please provide:
Duration of follow-up (e.g., 3, 6, 12 months)
Clinical and imaging outcomes
Antithrombotic strategy post-closure

-Overinterpretation of Imaging Findings
While IVUS excludes plaque rupture , the manuscript assumes embolism = only remaining explanation

This is not totally methodologically correct.

IVUS does NOT exclude iIn situ thrombosis without plaque rupture and transient vasospasm with thrombosis

Recommendation:
Temper statements such as:
“strongly favored an embolic mechanism”
Replace with:
“supports, but does not confirm”

-Lack of Standardized Reporting (CARE Checklist Not Addressed)
The manuscript does not explicitly adhere to CARE guidelines
Missing elements:
Patient perspective
Timeline
Diagnostic reasoning transparency
Explicit limitations section (case-specific)

Recommendation:
Add a CARE-compliant section or checklist

Author Response

see attachment

Author Response File: Author Response.pdf

Round 2

Reviewer 3 Report

Comments and Suggestions for Authors

The authors addressed all comments.