Paradoxical embolism in the left main coronary artery: diagnosis by transesophageal echocardiography.

We describe a patient with a paradoxical coronary embolism diagnosed by transesophageal echocardiography. The patient developed a stroke followed by a myocardial infarction. Coronary angiography showed an obstruction of the left main coronary artery. Transesophageal echocardiography showed the mechanism of the neurologic and cardiac events to be a paradoxical embolism. Emergency surgical retrieval of the thrombus lodged in the left main coronary ostium and of a separate thrombus traversing a patent foramen ovale was performed. To our knowledge, direct visualization of the paradoxical coronary embolism by echocardiography has not been reported previously. We discuss mechanisms responsible for paradoxical coronary embolism and review the literature pertaining to this condition.