coronary artery embolism is an established cause of acute coronary syndrome , but paradoxical coronary artery embolism causing myocardial infarction is rare and requires a high degree of clinical suspicion for diagnosis . recognition of this condition is important as these patients are at risk of future fatal embolic phenomena . percutaneous device closure of interatrial communication either in the form of patent foramen ovale ( pfo ) or atrial septal defect ( asd ) should be considered to prevent future embolism . a 64-year - old male with multiple myeloma was admitted for autologous stem cell transplantation . two weeks previous he was diagnosed with a peripherally inserted central catheter ( picc)-related right basilic and axillary vein thrombosis [ figure 1a , arrows ] complicated by pulmonary embolism that was treated with low molecular weight heparin . ( b ) right coronary angiogram showing flush occlusion of posterior descending artery and posterolateral branch of right coronary artery . ( c ) transesophageal echocardiography ( tee ) with agitated saline showing bubbles crossing the patent foramen ovale ( pfo ) . ( e ) tee showing a thrombus in superior vena cava during an attempt at picc removal , the patient coughed and developed sudden severe left - sided chest pain . an electrocardiogram showed st segment elevation in inferior ( ii , iii , and avf ) leads . cardiac biomarkers were elevated ( troponin - t 2.230 ng / ml ( normal < 0.01 ng / ml ) and creatine kinase myocardial band fraction 65.1 ng / ml ( normal < 6.7 ng / ml ) ) . coronary angiography revealed flush occlusion of the posterior descending artery and posterolateral branch of the right coronary artery [ figure 1b , arrows ] . severe thrombocytopenia ( platelet count 37  109/l ) secondary to newly diagnosed heparin - induced thrombocytopenia precluded use of antiplatelet agents and hence , coronary intervention . transesophageal echocardiography with agitated saline showed a small pfo ( figure 1c , arrow ) with bidirectional shunt seen on color doppler imaging [ figure 1d , asterix ] . in addition , a large thrombus was seen in the superior vena cava [ figure 1e , arrow ] . a diagnosis of st elevation myocardial infarction secondary to paradoxical embolism to the right coronary artery was entertained . in addition to long - term treatment with fondaparinux for venous thrombosis , percutaneous pfo closure was recommended to prevent recurrent embolism . paradoxical coronary embolism is rare and accounts for 1015% . of all paradoxical emboli , and 25% of acute coronary events in patients our patient had a documented picc associated thrombus , and an episode of cough preceding the onset of chest pain caused transient elevation in right atrial pressure with right to left shunting and paradoxical embolism though a pfo . the valsalva maneuver is routinely used to demonstrate shunting across the pfo during echocardiographic examination in individuals in whom spontaneous shunting is not seen . paradoxical embolism was first reported by cohnheim in 1877 and is known to cause cerebral , peripheral arterial , and in rare instances coronary artery occlusion . paradoxical coronary artery embolism should be suspected in patients who otherwise are at low risk for atherosclerotic coronary artery disease . in a given clinical scenario , demonstration of venoarterial communication ( most often at the atrial level ) together with identification of a venous source of embolus and lack of thrombi in the left heart fulfill the criteria for presumptive diagnosis of this condition . a definite diagnosis requires demonstration of thrombus across the venoarterial communication either by echocardiography or contrast computed tomographic angiography of the chest . many times paradoxical coronary artery embolism can only be made at the time of autopsy . when suspected clinically , a search for an underlying condition predisposing to venous thrombosis should be undertaken . the management of acute coronary syndrome caused by paradoxical coronary artery embolism is similar to that occurring in the setting of atherosclerotic coronary artery disease . manual aspiration thrombectomy with or without angioplasty and stenting followed by aggressive medical management including antiplatelet agents , is the standard of practice . the management of patients with contraindication to antiplatelet therapy may be challenging as in this case . aspiration and manual thrombectomy should be the main therapeutic intervention in such a situation unless the embolus is distal in a small coronary artery . optimum therapeutic strategy in preventing recurrent embolic events in patients with pfo is not established . a recent meta - analysis of three randomized clinical trials addressing the role of transcutaneous closure of pfo showed a benefit in preventing recurrent cerebrovascular ischemic events in patients with cryptogenic stroke when compared with medical therapy . another study demonstrated lower recurrent neurological event rates with amplatzer compared with cardioseal - starflex and helex devices . although percutaneous device closure has not been studied in paradoxical coronary embolism , it should be considered to prevent fatal recurrent events . in summary , in addition to acute management of acute coronary syndrome , pfo closure to prevent recurrent thromboembolism should be considered .