Diagnostic dilemma in a middle-aged man with heart failure

We report a middle-age man presented with shortness of breath. Echocardiography revealed globally hypokinetic LV with poor function. Coronary angiograms showed no obstructive coronary artery lesions but multiple coronary fistulae to pulmonary artery without significant left to right shunt. Cardiac magnetic resonance imaging demonstrated normal myocardial perfusion and absence of myocardial scarring. His condition improved with medications with fistulae left untreated. This case illustrates the importance of functional assessment of a rare clinical condition (coronary fistula) in patients with common clinical presentation (congestive heart failure) prior to definitive treatment.