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A 55 year old woman presented with acute chest pain of four hours’ duration. Her medical history revealed she suffered from chronic depression, which was treated with a monoamine oxidase inhibitor. She also smoked cigarettes. On admission, the patient was normotensive (systolic blood pressure 125 mm Hg), had no signs of congestive heart failure, and had normal peripheral pulse. No murmurs were heard on auscultation. The ECG showed a regular sinus rhythm of 85/min and signs of an acute anterolateral infarction. The patient was transferred immediately to the catheterisation laboratory where aspirin, heparin, and glyceryl trinitrate were administered intravenously and emergency coronary angiography was performed. In the left coronary artery, the left anterior descending branch was proximally occluded. Also the posterolateral branch of the ramus circumflexus was occluded (upper panel, centre). The right coronary artery appeared to be normal. In the sinus of Valsalva a round structure was seen, indicative of embolisation of the left coronary artery (lower panel, centre). Subsequently, primary angioplasty of the left anterior descending coronary artery was performed, but blood flow could not be restored. Transoesophageal echocardiography revealed an echodense structure 0.5 × 1 cm, located in the left coronary sinus of Valsalva, just proximal to the ostium of the left coronary artery (upper and lower panels, right). The aortic root itself showed no abnormalities. Suspecting that a thrombus in the sinus of Valsalva with embolisation was the cause of the coronary occlusion, thrombolysis was administered intravenously. However, no signs of reperfusion were seen. The following day the patient’s haemodynamics deteriorated and, despite maximal cardiac and respiratory support, she died. No permission for necropsy was given.