Background A paradoxical embolism arises when a venous thrombus passes through a cardiac right to left shunt and enters the arterial circulation. This can manifest as cardiovascular ischemia, cerebrovascular insults, increased right ventricular pressure, and/or volume overload leading to signs and symptoms of heart failure. While rare, paradoxical emboli carry high mortality and morbidity if diagnosis is missed and/or treatment is delayed. Transesophageal echocardiography can be diagnostic. Initial treatment revolves around anticoagulation and/or thrombolysis to prevent clot propagation. However, for clots in transit, emergent surgical removal is often necessary. Anesthetic induction can be tricky given the potential for rapid deterioration and the need to avoid increased right sided pressures and further clot migration. Case presentation In this report, we present a 72-year-old obese female with a history of hypertension, hyperlipidemia, gout, and diabetes found to have a paradoxical embolism caught in transit, trapped in a patent foramen ovale, and managed surgically. We describe the role of intraoperative transesophageal echocardiography in successfully treating this patient. Conclusions TEE plays an important role in the diagnosis and management of paradoxical PE. It can detect right and left heart thrombi and intracardiac shunts , can help in the successful closure of intracardiac shunts, and can impact intraoperative surgical decision making.