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A 50 year old man underwent a myocardial perfusion scan at rest for chest pain evaluation. He received an intravenous injection of Tc-99 sestamibi, while complaining of recurring angina, and underwent a single photon emission computed tomography (SPECT) scan approximately 90 minutes later. An initial planar image acquisition showed a very prominent retention of the tracer in the lungs, with a lung:heart ratio of 0.98 (normal reference < 0.44) (panel A). The tomographic images of the myocardium showed severe anterior, septal and lateral hypoperfusion with significant systolic dysfunction. After image acquisition, the patient presented with worsening dyspnoea and haemoptysis compatible with evolving acute pulmonary oedema. After adequate response to medical treatment, he was sent to the cath lab, having shown a severe lesion at the left coronary ostium. He underwent coronary bypass graft surgery with subsequent complete remission of the symptoms. A control myocardial perfusion scan at rest performed eight days after surgery showed the lung:heart ratio (0.40) had returned to normal with normal segmental myocardial perfusion (panel B). This unusual presentation depicted in panel A represents severe left ventricular failure reflecting subtotal left main coronary artery occlusion, and was decisive for ensuring adequate patient management.