A 59-year-old man was referred to our department for further investigation of abnormal findings on an echocardiography. He had a history of hypertension and cerebral hemorrhage. He suffered distal interphalangeal joint deformity in his right third finger and underwent routine preoperative evaluation. His electrocardiogram (ECG) and chest X-ray were normal. Transthoracic echocardiography showed an abnormal Doppler color flow, through the left ventricle (LV) wall to the basal part of the ventricular cavity. Left ventricular systolic and diastolic functions were normal with normal chamber sizes. Selective coronary angiography demonstrated a normal right coronary artery. The left anterior descending artery (LAD) and the left circumflex artery (LCX) were large and tortuous without stenosis. They merged at the end of their course near the basal inferoposterior wall of the LV, and formed a huge fistulous track draining into the LV cavity (Fig. 1). Due to its large size, FFR was measured in both arteries. During hyperemia, obtained by an intravenous adenosine infusion (140 µg/kg/min), the FFR values were 0.93 in the LAD and 0.97 in the LCX (Fig. 2). The LV end-diastolic pressure was normal (11 mm Hg). He subsequently completed 17 minutes of a treadmill test (Bruce protocol) without chest pain and abnormal ECG changes. Due to the lack of symptom and evidence of hemodynamic compromise, we decided to leave the fistula alone and follow the patient closely. He had undergone an orthopedic surgery, uneventfully.

A 73-year-old woman was admitted to the hospital with dyspnea on exertion for one month. She underwent a total gastrectomy, due to advanced gastric cancer, 13 years ago. She had a history of diabetes mellitus and was on antianginal medication. Her resting ECG demonstrated a sinus rhythm with anterolateral and inferior T-wave inversions. The chest X-ray exhibited cardiomegaly. Transthoracic echocardiography showed a hypertrophied LV wall with an average thickness of 12 mm. The LV systolic function was normal with impaired relaxation patterns. Selective coronary angiography revealed normal right coronary artery and multiple coronary-left ventricular fistulas, arising from the left coronary artery system. A severe myocardial bridge, with total obstruction at the systolic phase, was observed in the mid segment of the LAD (Fig. 3). The FFR measurement was performed to evaluate the hemodynamic consequences, resulting from the myocardial bridge and the fistulas. The FFR value of the LAD was obtained by an intravenous adenosine infusion (140 µg/kg/min). During hyperemia, the FFR value was 0.92 in the LAD, beyond the bridging segment. The pressure pull back tracing showed that the FFR value increased from 0.92 to 0.94 in the segment that was proximal to the bridge (Fig. 4). Notably, the intracoronary systolic pressure overshooting was followed by the abrupt early diastolic pressure gradient in the distal segment beyond the bridge (Fig. 4B). Those findings disappeared immediately after the sensor proceeded through the bridging segment into the proximal segment of the LAD with a pull-back maneuver. The multiplicity of the fistulas and the lack of evidence of ischemia, we concurred to manage the patient medically.