Coronary Artery to Left Ventricle Fistula with Unique Myocardial Perfusion Imaging

An 82-year-old woman visited our hospital because of chest pain that she had been experiencing since her teenage years. A 12-lead electrocardiogram showed a flat T-wave in leads V4-V6. Transthoracic echocardiography revealed normal left ventricular (LV) wall motion. At the apex, color Doppler echocardiography demonstrated an unusual myocardial flow pattern, directed from the epicardium to the LV lumen during diastole and reversing during systole, findings diagnostic of a myocardial sinusoid. Cardiac computed tomography (CCT) revealed interruption of the left anterior descending artery. Rest myocardial perfusion imaging derived from CCT revealed a unique finding of hyperperfusion during diastole and hypoperfusion during systole at the sinusoid. These findings demonstrate the utility of CCT in identifying coronary artery ventricle fistulas.