Clinical introduction A 77-year-old female was referred for evaluation of an episode of syncope while eating breakfast. There was no history of fall, syncope, prodrome, dyspnoea, chest discomfort or palpitations. Medical history was notable for hyperlipidaemia and treated hypertension. Blood pressure was 140/90 mm Hg, pulse 85 beats per minute (BPM). No murmurs were present on cardiac examination. ECG revealed normal sinus rhythm with left ventricular (LV) hypertrophy (see online supplementary figure S1). Holter monitor demonstrated rare premature ventricular complexes (<1% of beats), without heart block or ventricular tachycardia. Transthoracic echocardiogram is shown in figure 1.
Question Which of the following is the explanation for the flow indicated by the yellow arrow?
Coronary artery flow, indicative of coronary fistula
Hypertrophic cardiomyopathy with apical pouch
Hypertensive heart disease
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Contributors All authors participated in authoring of the submitted manuscript. All authors have reviewed the manuscript and approved the submitted version.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.