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Echocardiographic demonstration of multiple coronary artery–left ventricular microfistulae
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A 68 year old woman was referred for evaluation of chest pain. The patient had a six month history of typical angina occurring with moderate exertion. She had a 10 year history of hypertension. Her blood pressure was 150/90 mm Hg. Precordial examination was normal with no murmur. The ECG recorded during chest pain showed symmetrical and deep T wave inversion (A). Left ventriculography showed a normal sized left ventricle with an ejection fraction of 65%. Left ventricular end diastolic pressure was 8 mm Hg. Coronary angiography revealed normal epicardial coronary arteries. After contrast injection the left ventricle was seen to fill faintly at end diastole with contrast from a diffuse plexus of fine vessels arising from the mid to distal portion of the left anterior descending coronary artery (B, left). The coronary sinus was normal. Transthoracic colour Doppler echocardiogram just beneath the apical impulse window, using a high frequency transducer with a special preset coronary program with a low Nyquist limit, showed the presence of multiple linear colour flow signals perpendicular to the epicardial surface in the left ventricular apex, demonstrating penetrating intramyocardial coronary arteries arising from the left anterior descending coronary artery (B, right).