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Global left ventricular function can be estimated by recording mitral annular velocity. The implementation of a cutoff limit of 8 cm/sec gave a simple guide for differentiating between normal and abnormal left ventricular systolic function that might be useful clinically in patients without regional wall-motion abnormalities. However, in patients with important segmental wall-motion abnormalities during systole, left ventricular longitudinal shortening is an imperfect surrogate for ejection fraction.

An 86-year-old lady presented with an acute inferior ST elevation myocardial infarction. The coronary angiogram showed a thrombotic occlusion of the right coronary artery, which was aspirated, but there was no underlying lesion to stent. The patient remained very hypoxic on the ward with clear lung fields and was found to also have multiple pulmonary emboli on CT pulmonary angiogram. Paradoxical embolism was suspected as the cause of myocardial infarction and subsequent echocardiography studies indeed confirmed the presence of a patent foramen ovale. Although rare, this mechanism should be considered in patients presenting with acute coronary syndromes without significant underlying coronary artery disease.

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