An Unexpected Cause of STEMI in Partially Repaired Tetralogy of Fallot

BACKGROUND: Coronary embolism (CE) is an uncommon but clinically relevant nonatherosclerotic cause of ST-elevation myocardial infarction (STEMI). Adult patients with congenital heart disease may be particularly vulnerable when residual intracardiac shunts, atrial enlargement, and atrial arrhythmias coexist. CASE SUMMARY: A 77-year-old man with partially repaired tetralogy of Fallot, residual ventricular septal defect with bidirectional shunting, and new-onset atrial fibrillation presented with inferior STEMI. Coronary angiography revealed distal right coronary artery occlusion with a large thrombus burden, in the absence of significant atherosclerotic disease. Sustained mechanical aspiration thrombectomy was successfully performed, with clinical and electrocardiographic improvement. DISCUSSION: To the best of our knowledge, this is the first reported case of sustained mechanical aspiration thrombectomy for STEMI due to CE in an adult patient with congenital heart disease with residual intracardiac shunt. TAKE-HOME MESSAGE: In adult patients with congenital heart disease with STEMI, CE should be suspected when intracardiac shunts and embolic risk factors coexist.