Adult female who started having chest pain in the setting of using cocaine overnight. No significant past medical history. She presented to the ED with hypotension and ST elevation. Peak troponin level was 45.

STEMI code was called with stat transfer to the cardiac cath lab, which showed non-obstructive coronaries. Right heart catheterization did show a severely elevated pulmonary artery pressure.

Transthoracic echocardiogram showed a dilated and severely depressed right ventricle. After left heart catheterization the patient remained hypotensive and so was started on norepinephrine.

Concern was made for possible PE vs shunt given right atrial oxygen saturation was mid-to-high 20s and pulmonary artery saturation was mid-30s.

CTPA was obtained, which was negative for PE. Bubble study was obtained with TTE, which was negative for a shunt.

The patient remained on pressors. A right radial arterial line was placed and RIJ TLC was placed. She was transferred to a cardiac center for possible RVAD or transplant.

The patient improved with treatment and was discharged one week later from there without RVAD, ECMO or cardiac transplant.

See reference 1 below, this is a similar case.