Valsalva Leading to Pain in the Left Arm: A Case of Paradoxical Embolism

Paradoxical embolism (PDE) secondary to a patent foramen ovale (PFO) is an underdiagnosed condition with potentially severe clinical outcomes, including stroke, myocardial infarction, migraines, and peripheral arterial embolism. PFO is typically asymptomatic and often requires a high index of suspicion for a proper diagnosis. We report a case of a 36-year-old male smoker with a medical history significant for pulmonary thromboembolism, deep vein thrombosis (DVT) of the right lower extremity (RLE), type 1 diabetes mellitus (T1DM), and coronary artery disease (CAD). The patient presented with sudden-onset left arm pain after recreational activity. Physical examination revealed a hemodynamically stable individual with findings suggestive of ischemia in the fourth and fifth digits of the left hand. Initial diagnostic workup including duplex ultrasound, CT angiography (CTA), and transthoracic echocardiography (TTE) suggested left ulnar artery thrombosis, with TTE negative for cardiac septal abnormalities. Following the thrombectomy, he experienced complete symptom resolution upon discharge. However, two weeks later, he returned with identical symptoms and clinical findings. Subsequent investigations, including transesophageal echocardiography (TEE) with a bubble study, confirmed the presence of a PFO. The recurrent thrombotic event was attributed to a PDE facilitated by the PFO. Definitive management involved PFO closure using a septal occluder device, resulting in the successful resolution of symptoms. This report highlights the importance of considering PFO in patients with unexplained recurrent embolic events and underscores the value of advanced imaging modalities, such as TEE, in establishing the diagnosis.