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A 60 year old white man with history of hypertensive heart disease had complained of dyspnoea for a month. Newly developed atrial fibrillation caused symptomatic deterioration. Routine precardioversion transoesophageal echocardiography to rule out left atrial thrombus under oral anticoagulation had revealed a mosaic pattern in the left main coronary artery (LMCA) ostium. Colour Doppler imaging was performed to determine whether there was a significant left main coronary artery lesion. Coronary angiography showed ostial stenosis of the left main coronary artery without any other lesion in the left or right coronary artery system. We detected 35% diameter stenosis and 58% area stenosis in the LMCA ostium. Minimal lumen diameter and reference segment diameter were calculated to be 3.13 mm and 4.83 mm, respectively. Although the lumen diameter (> 3 mm) was sufficient for coronary artery perfusion, intravascular ultrasound imaging was performed, which showed a non-critical eccentric lesion with mixed plaque composition, causing 27% diameter stenosis and 46.5% area stenosis. The patient underwent cardioversion safely.