BACKGROUND In the development of coronary stent technology, bioresorbable scaffolds are promising milestones in improving the clinical treatment of coronary artery disease. The "leave nothing behind" motto is the premise of the fourth revolution in percutaneous coronary intervention (PCI). Studies proving the safety and efficacy of the magnesium-based resorbable scaffolds (MgBRSs) include the BIOSOLVE-I and BIOSOLVE-II trials and the latest BIOSOLVE-IV registry. However, spontaneous retrograde dissection of a partially absorbed MgBRS may still occur, albeit rarely. CASE SUMMARY We describe an unusual case of coronary artery disease in a patient who had undergone a successful PCI 8 mo earlier, where an MgBRS was implanted into the left anterior descending artery (LAD) and left circumflex artery with drug-coated balloons for a ramus intermedius branch stenosis to achieve the "leave nothing behind" therapeutic intention and was currently presenting with a gradual worsening of chest tightness. The distal edge vascular response, during subsequent attempts with balloon angioplasty was performed smoothly. However, spontaneous retrograde dissection of a partially absorbed MgBRS in the LAD ensued. Successful bailout stenting was performed with revascularization of the entry and exit sites created by spontaneous dissection and complete sealing of the intramural hematoma. The patient recovered well and was discharged after 2 d of intervention. When followed up in August 2020 (7 mo later), the patient showed uneventful recovery. CONCLUSION Spontaneous retrograde dissection of a partially absorbed MgBRS was successfully treated using bailout sirolimus-eluting coronary stent strategy.

BACKGROUND Despite improvements in percutaneous coronary intervention (PCI) devices and operator expertise, coronary chronic total occlusion (CTO) poses a management dilemma for interventional cardiologists. Occasionally, in CTO lesions and in bifurcation lesions with severe curvature and stenosis, wires cannot be introduced into the main artery, although wiring into the side branch is possible. We herein report a case of stumpless ostial left anterior descending artery (LAD) CTO that was successfully treated with a novel strategy. CASE REPORT A 64-year-old female with symptoms of heart failure was admitted to our hospital. Coronary angiography showed CTO of the stumpless ostial LAD. The patient had invisible and continuous collaterals; therefore, we used the antegrade approach for CTO access. However, the wire could be guided only in the direction of the diagonal branch due to a severe angulation at the CTO exit site, despite successful wire crossing into the CTO lesion. We attempted intravascular ultrasound-guided direct wire entry technique to obtain additional information about the occlusion cap location and to assist in negotiating the wire into the true lumen. The guidewire (Conquest pro) could cross the lesion after several approaches and successfully advance the device over the wire through the occluded segment after the modified See-saw wiring technique was employed. CONCLUSIONS This method appears to be a promising novel strategy for difficult and complex lesions when performing CTO revascularization.

BACKGROUND:Studies have reported that women with ST elevation myocardial infarction (STEMI) have worse short- and long-term outcomes than men. It has not yet been confirmed whether these differences reflect differences in age between men and women.METHODS:We retrospectively enrolled 1035 consecutive STEMI patients treated with primary percutaneous coronary intervention (PCI). Baseline clinical characteristics, coronary anatomy, and outcome were compared between young (< 65 years old) and older patients (≥ 65 years old) of both sexes.RESULTS:Younger women presented with a lower incidence of typical angina (83% vs. 93%, p = 0.03), single-vessel disease (21% vs. 35%, p = 0.03), and total occlusion of infarct-related artery (65% vs. 83%, p = 0.001) than younger men, with no gender difference noted in the older group. Younger women in the study had a higher incidence of reinfarction, heart failure requiring admission, or mortality (23% vs. 6%, p < 0.001) during follow-up, compared with younger men, with no gender difference in the older group. Using the Kaplan-Meier analysis, younger women had lower rates of event-free survival (p < 0.001 by log-rank test) than younger men, with no gender difference in the older group. In multivariate analysis, age could predict long-term outcome in men (Hazard ratio 4.43, 95% confidence interval: 2.89-6.78, p < 0.001) but not in women.CONCLUSIONS:In STEMI patients receiving primary PCI, sex-related long-term outcome differences were age-dependent, with younger women likely to have a worse long-term outcome when compared with younger men.KEY WORDS:Coronary heart disease; Gender; Myocardial infarction.

An anomalous right coronary artery (RCA) arising from the left sinus of Valsalva is a rare congenital coronary anomaly. Although there are reports of percutaneous coronary intervention (PCI) for atherosclerotic lesions of this unusual coronary anomaly, only four cases of acute ST-segment elevation myocardial infarction caused by thrombotic occlusion of an anomalous RCA managed with primary PCI have been documented previously. Herein, we describe a 65-year-old man who had successful PCI in an anomalous RCA in the clinical setting of acute myocardial infarction. The patient was discharged a few days later and has been well during OPD follow-up.

BACKGROUND:Coronary artery fistula (CAF) is an anomaly resulting in the steal phenomenon of coronary blood flow, which may cause morbidity or mortality. CAFs in Chinese patients after long-term follow-up of 15 years were retrospectively analyzed.METHODS AND RESULTS:From September, 1992 to August, 2007, 152 CAFs were detected in 28,210 coronary angiograms from 125 patients. Clinical and angiographic data of all patients were analyzed retrospectively. Two types of CAFs were characterized: type I in 99 patients with 124 solitary coronary to cardiac chamber or great vessel fistula; type II: 26 patients with 28 coronary artery--left ventricular multiple microfistulas. Single-, double-, and triple-CAFs were detected in 79%, 20%, and 1% of patients, respectively. Coexistent coronary lesions were noted in 41% of patients. Fistula-related symptoms included stable angina in 55, myocardial infarction in 2, heart failure in 2, sudden death with ventricular fibrillation in 1, and syncope in 1. Twenty-four patients had coexistent congenital anomalies. Only 9 patients underwent coronary intervention or/and surgery for CAFs.CONCLUSIONS:CAFs may cause trivial or lethal cardiac events, and may coexist with coronary lesion or congenital anomaly. Coronary to cardiac chamber or great vessel fistula and coronary-left ventricular multiple microfistulas have different morphologic and pathological phenomena.

The purpose of this study was to investigate the predictor of long-term outcomes in patients after stent implantation for unprotected left main coronary artery (LMCA) disease. Coronary stenting has recently been advocated as an alternative procedure for LMCA disease. Information on the predictors of long-term outcomes in patients after stent implantation for unprotected LMCA disease is not clear. Seventy six patients (51 men and 25 women, age 68 ± 10 years) with medically refractory angina received coronary stenting for unprotected LMCA disease. During a follow-up period of 40 ± 26 months, 7 patients (9%) died because of cardiovascular disease in 5 (7%) and noncardiovascular disease in 2 (3%). In the other 69 patients, 19 patients (25%) needed repeated percutaneous coronary intervention (PCI) and/or coronary artery bypass grafting (CABG). In a univariate analysis, only female sex was related to the repeated PCI and/or CABG (P = 0.04). A history of cerebral vascular attack (CVA) (P = 0.005), anemia (P = 0.03) and lower left ventricular ejection fraction (LVEF) (P = 0.008) were related to the cardiovascular mortality. A history of myocardial infarction (P = 0.03), a history of CVA (P = 0.02), anemia (P = 0.02), and lower LVEF (P = 0.002) were related to the total mortality. In a multivariate analysis, female sex (P = 0.007; odds ratio 5.29, 95% confidence interval [CI] 1.57–17.80) and young age (P = 0.025; odds ratio 3.92, 95% CI 1.19–12.98) could predict the repeated PCI and/or CABG. Only a history of CVA could predict the cardiovascular mortality (P = 0.027; odds ratio 34.18, 95% CI 1.49–783) and only lower LVEF could predict the total mortality (P = 0.027; odds ratio 13.26, 95% CI 1.34–131). Female sex and young age could predict the repeated PCI and/or CABG in patients after stent implantation for unprotected LMCA disease. Furthermore, a history of CVA could predict the cardiovascular mortality and lower LVEF could predict the total mortality.

Background: Coronary fistula is a congenital anomaly resulting in steal phenomenon of coronary blood flow, which may result in clinical symptoms and/or signs of coronary artery disease (CAD), including angina pectoris, myocardial ischemia, and congestive heart failure. The purpose of this study is to do a retrospective analysis of myocardial ischemia in 201TI images in patients with coronary fistulae. Methods: From September, 1992 to December, 2006, 26,758 cases underwent coronary angiography in our hospital and 58 of them (0.22%, 32 male; mean age 62±14, range from 35 to 87 years old), with chest pain and/or chest tightness underwent stress test for CAD. All patients received dipyridamole as pharmacological stress. All patients were followed by image acquisitions done immediately after stress and 4 h later. Results: All patients revealed coronary fistula by coronary angiography. Origin, drainage site, and diameter (large fistula ≥ 10 mm, small fistula ＜ 10 mm) of each fistula were recorded. Fifty seven patients (98%) had 201Tl perfusion defects in either reverse [R], partial reverse [PR], or reverse redistribution [RR] patterns. In the 201TI SPECTs, 82 abnormal perfusion areas were found including 52R (63%), 21PR (26%), and 9RR (11%). In all coronary fistulae, 64% (28/44) in LAD could see 201Tl perfusion defects in anterior, septal, and/or apical areas. In addition, 71% (5/7) in LCX could detect defects in lateral or inferior areas, and 70% (14/20) in RCA could detect defects in inferior and/or lateral areas. In fistulae without 201TI perfusion defect in corresponding territories, micro-fistulae were noted in 81% (13/16) of fistulae in LAD, 100% (3/3) of fistulae in LCX, and 83% (5/6) of fistulae in RCA. Conclusions: Myocardial ischemia with abnormal 201TI perfusion image can be detected in large portion of patients with coronary fistulae. Coronary fistulae with ischemia in 201TI perfusion images also can be associated with chest pain and/or chest tightness. The absence of 201TI perfusion defect in patients with coronary fistula may be due to micro-fistula without evident steal phenomenon of coronary blood flow.

Background: Myocardial bridge (MB) is an congenital coronary anomaly resulting in systolic narrowing of coronary artery. It may be seen occasionally during coronary angiography (CAG) examinations and may cause clinical symptoms and/or signs of coronary artery disease (CAD). The symptoms/signs include angina pectoris, myocardial infarction, vasospasm, cardiac arrythmia, and sudden cardiac death. Few previous reports stated about the (superscript 201)TI perfusion defects noted in patients with MB, which probably imply the evidence of myocardial ischemia. The purpose of this study is to do a retrospective analysis of (superscript 201)TI images in patients with MB. Methods: From July, 2000 to June, 2003, 63 patients (30 male; mean age 57±10, and range from 33 to 80 years old), with chest pain and/or chest tightness underwent stress test for CAD. Six patients underwent treadmill exercise with Bruce protocol and 57 patients received dipyridamole as pharmacological stress. All patients were followed by image acquisitions done immediately after stress and 4 h later. All underwent CAG subsequently to identify the severity of CAD. Results: In all of the 63 patients, CAG revealed MB. Fifty patients had MB in left descending artery (LAD) (40 at mid portion; 8 at distal portion; 2 at mid and distal portion), 4 in left circumflex artery (LCX), and 1 in right coronary artery (RCA). Seven patients had MB in both LAD and LCX, and 1 patient had MB in both LAD and RCA. Sixty patients (95%) had (superscript 201)TI perfusion defects in either reverse (R), partial reverse (PR), or reverse redistribution (RR) patterns. In the abnormal (superscript 201)TI SPECTs, 103 abnormal perfusion areas were found including 57 R (55%), 40 PR (39%), and 6 RR (6%). In all vessels with MB, 48 (83%) in LAD could see (superscript 201)TI perfusion defects in anterior, septal, and/or apical areas. In addition, 6 of 11 (55%) in LCX could detect defects in lateral or inferior areas, and 2 of 2 (100%) in RCA could detect defects in inferior areas. Conclusions: Myocardial ischemia with abnormal (superscript 201)TI perfusion image can be detected in most patients with MB. MB with ischemic evidence in (superscript 201)TI perfusion image also may be associated with chest pain and/or chest tightness in our patients. (superscript 201)TI perfusion defect may be presented with R, PR, or RR in patients with MB. The significance of three different perfusion defects patterns (R, PR, and RR) may represent the various severity of perfusion insufficiency induced by MB.

Introduction: Functional and structural changes of atrial tissue occur during the natural course of atrial fibrillation (AF), and these changes may contribute to further AF. We investigated the changes in AF tissue using cDNA microarray and two‐dimensional protein electrophoresis techniques. Methods and Results: We established a porcine model of AF by rapid right atrial appendage pacing at a rate of 600/min. Atrial tissue was obtained after rapid atrial depolarization for 6 weeks. Microarrays containing 6,035 cDNA clones were used to evaluate the alterations of mRNA. Two‐dimensional protein electrophoresis was performed to compare protein patterns. In cDNA microarray studies, we identified 387 genes with significant change in the left atrium and 81 genes in the right atrium. Among the genes, the ventricular isoform of the myosin regulatory light chain (MLC‐2V) showed the greatest fold of change (9.4 and 7.3 in the left and right atrium, respectively). In protein electrophoresis, the expression levels of three protein spots spanning from 18 to 20 kDa in the acidic region (PI 4.5–5.0) were specifically elevated in the AF group. Interestingly, through tandem mass spectrometric analysis, these three spots were identified as MLC‐2V. Thus, MLC‐2V expression at the mRNA and protein levels corresponded well, and both indicated a significant increase in AF. Conclusion: Both cDNA microarray and two‐dimensional polyacrylamide protein electrophoresis studies revealed characteristic changes in AF tissue. We demonstrated the reprogramming of myosin regulatory light chain isoform composition, with a significant increase of its ventricular isoform (MLC‐2V). (J Cardiovasc Electrophysiol, Vol. 15, pp. 214‐223, February 2004)

Background: Myocardial bridge (MB) is an congenital coronary anomaly resulting in systolic narrowing of coronary artery. It may be seen occasionally during coronary angiography (CAG) examinations and may cause clinical symptoms and/or signs of coronary artery disease (CAD). The symptoms/signs include angina pectoris, myocardial infarction, vasospasm, cardiac arrythmia, and sudden cardiac death. Few previous reports stated about the 201 Tl perfusion defects noted in patients with MB, which probably imply the evidence of myocardial ischemia. The purpose of this study is to do a retrospective analysis of 201 Tl images in patients with MB. (30 male; mean age 57 ± 10, and range from 33 to 80 years old), with chest pain and/or chest tightness underwent stress test for CAD. Six patients underwent treadmill exercise with Bruce protocol and 57 patients received dipyridamole as pharmacological stress. All patients were followed by image acquisitions done immediately after stress and 4 h later. All underwent CAG subsequently to identify the severity of CAD. Results: In all of the 63 patients, CAG revealed MB. Fifty patients had MB in left descending artery (LAD) (40 at mid portion; 8 at distal portion; 2 at mid and distal portion), 4 in left circumflex artery (LCX), and 1 in right coronary artery (RCA). Seven patients had MB in both LAD and LCX, and 1 patient had MB in both LAD and RCA. Sixty patients (95%) had 201 Tl perfusion defects in either reverse (R), partial reverse (PR), or reverse redistribution (RR) patterns. In the abnormal 201 Tl SPECTs, 103 abnormal perfusion areas were found including 57 R (55%), 40 PR (39%), and 6 RR (6%). In all vessels with MB, 48 (83%) in LAD could see 201 Tl perfusion defects in anterior, septal, and/or apical areas. In addition, 6 of 11 (55%) in LCX could detect defects in lateral or inferior areas, and 2 of 2 (100%) in RCA could detect defects in inferior areas. Conclusions: Myocardial ischemia with abnormal 201 Tl perfusion image can be detected in most patients with MB. MB with ischemic evidence in 201 Tl perfusion image also may be associated with chest pain and/or chest tightness in our patients. 201 Tl perfusion defect may be presented with R, PR, or RR in patients with MB. The significance of three different perfusion defects patterns (R, PR, and RR) may represent the various severity of perfusion insufficiency induced by MB.

Left main coronary artery (LMCA) disease is now uniformly treated with coronary artery bypass grafting (CABG). However, some patients with LMCA disease do not receive CABG because of high operative risks. The advent of stent implantation has permitted a non-operative improvement in myocardial blood flow in many patients with single- and multi-vessel coronary artery disease. However, the outcomes of stent implantation for unprotected LMCA disease are still unclear. Stent implantation was performed for unprotected LMCA disease in 13 patients; eight patients had high operative risk and five patients had refused CABG. The primary success rate was 100% (13/13 patients). One patient (8%) developed a non-Q-wave myocardial infarction after LMCA stenting. Repeat angiography was obtained in five patients (38%) with recurrent angina, and three patients (23%) received repeated percutaneous transluminal coronary angioplasty (PTCA) for LMCA restenosis. In the follow-up period of 18+/-3 months, 12 patients (92%) remained in satisfactory condition with no further need for surgical intervention. One patient (8%) ultimately required CABG, and she died after CABG at 3 months after LMCA stenting. In conclusion, although CABG remains the standard treatment for LMCA disease, the present study demonstrates that stent implantation is a safe and clinically beneficial revascularization procedure for unprotected LMCA disease in patients who have high operative risk as well as those who refuse CABG.

The purpose of this study was to validate the usefulness of transesophageal echocardiography (TEE) in the assessment of cardiovascular shunts in patients with pulmonary hypertension (PH) of unexplained cause. Twenty-four adult patients, 16 women, 8 men; 15 to 70 years of age, with PH of unexplained cause were studied. All were examined by transthoracic echocardiography (TTE) and TEE. TTE showed the ventricular septal defect in two patients, muscular type in one and perimembranous type in the other. TEE showed the atrial septal defect in eight patients (secundum type in six and primum type in the remaining) and the patent ductus arteriosus in six patients, which were not seen by TTE. The ventricular septal defect shown by TTE was also found by TEE. Patients with a ventricular septal defect were also associated with a patent ductus arteriosus. Among 14 patients with cardiovascular lesions, nine patients displayed a pattern of bidirectional shunt, four

Transesophageal echocardiography (TEE) has emerged as an efficient method for detecting left atrial (LA) thrombi in recent years, but its accuracy has not been fully evaluated. A prospective clinicopathologic study in 213 consecutive patients with chronic rheumatic mitral valve disease over a period of 39 months was undertaken. All patients underwent open heart surgery within 3 days after the TEE study. The presence or absence of LA thrombi was confirmed at surgery by direct inspection of the left atrium and proven by histopathologic examination. Of the 213 patients, 147 had predominant mitral stenosis, and the remaining 66 patients had significant mitral regurgitation. Twenty-eight patients had LA thrombi by TEE criteria. These findings were all confirmed at surgicopathologic studies (specificity 100%). However, in 2 patients, LA thrombi were present but could not be detected by TEE (sensitivity 93.3%) Therefore, the positive predictive value was 100%, the negative predictive value was 98.9% and the diagnostic accuracy was 99.1%. No thrombi were found in patients with significant mitral regurgitation. The frequency of LA thrombi in patients with predominant mitral stenosis was 20% (30 of 147), and most of these patients had chronic atrial fibrillation (28 of 30, 93%). Only 16 patients (16 of 30, 53%) were found to have LA thrombi by transthoracic echocardiography. Furthermore, our data showed poor correlation between the echogenicity of LA thrombi and the degree of thrombus organization. Thus, TEE is excellent for detecting LA thrombi in patients with rheumatic heart disease severe enough to warrant mitral valve operations.

To compare the accuracy of transesophageal echocardiography (TEE) with that of transthoracic echocardiography (TTE) in the detection of morphologic characteristics and in the quantitative assessment of the severity of mitral regurgitation with ruptured chordae tendineae, 40 patients with ruptured chordae tendineae (group 1) and 20 patients with moderate or severe mitral regurgitation due to other causes (group 2) were studied. All echocardiograms were recorded before cardiac surgery. Cardiac catheterization was performed in 55 patients (92%). TEE showed greater sensitivity and negative predictive value than TTE (100 vs 65%, and 100 vs 56%, respectively; p < 0.005) in the diagnosis of ruptured chordae tendineae. Visualization of the ruptured chordae (termed snake-tongue sign) was highly sensitive and specific (93 and 95%, respectively) for establishing the diagnosis of ruptured chordae tendineae. The severity of mitral regurgitation in group 1 patients evaluated by TTE color flow mapping was underestimated by 2 grades in 1 patient and by 1 grade in 6 patients, and overestimated by 1 grade in 1 patient, compared with left ventriculography. In contrast, by TEE color flow mapping it was underestimated by 1 grade in 1 and overestimated by 1 grade in 1 patient. TEE color flow mapping showed better correlation with angiography than did TTE color flow mapping (r = 0.82 vs r = 0.49).

To ascertain the incidence and significance of bacteremia associated with transesophageal echocardiography (TEE), 132 consecutive patients (aged 17 to 73 years) free of apparent infection who were undergoing 135 transesophageal echocardiographic procedures from October 1990 to August 1991, were prospectively studied. For each procedure, two sets of blood cultures were obtained for culture 30 to 60 minutes before TEE, immediately after, and 180 to 240 minutes after the procedure. For each blood culture, 10 ml of venous blood was evenly inoculated into aerobic and anaerobic culture bottles and inoculated for 7 days using a radiometric system. A throat swab was obtained immediately before each procedure. Three of 270 preprocedure blood cultures were positive for Bacillus cereus, Staphylococcus simulans, and Peptostreptococcus species, respectively. No blood culture was positive in the immediate postprocedure period. Two of 270 late blood samples grew Staphylococcus epidermidis in the same patient. Nevertheless, the microorganisms isolated from blood cultures were different from those isolated from the throat swab. No patients had fever or evidence of infective endocarditis after TEE during the follow-up period. It is concluded that the incidence of TEE-related bacteremia is extremely low, and a general recommendation for antibiotic prophylaxis during TEE is not warranted.

Systemic arterial embolization imparts a significant risk of serious complications throughout the lives of patients with rheumatic heart disease. Left atrial (LA) thrombi have been thought to be the major source of emboli. A transesophageal echocardiography (TEE) study of 260 consecutive patients with rheumatic mitral valve disease was performed during a period of 24 months, with particular reference to understanding the association between LA thrombi and embolic complications. Of these patients, 155 had predominant mitral stenosis, 24 had significant mitral regurgitation, and the remaining 81 with xenograft mitral valve replacement developed valvular dysfunction (25 resulted in predominant mitral stenosis and 56 in significant mitral regurgitation). LA thrombi were detected in 38 patients (group A) and absent in 222 (group B). Group A patients had a higher frequency of recent (≤1 week before TEE study) and remote (>1 week before) embolization than did group B patients (recent: 26.3 vs 5.4% [p < 0.001]; remote: 18.4 vs 5.0% [p < 0.01]). The frequency of atrial fibrillation was also greater in group A patients (100 vs 74.3%; p < 0.001). The exclusion of patients with significant mitral regurgitation and sinus rhythm had no effect on the association between LA thrombi and evidence of previous embolization. It is concluded that TEE is a convenient diagnostic modality that can be used to identify a subset of patients with rheumatic mitral valve disease at high risk for systemic embolization. Consequently, preventive anticoagulation for possible embolic complications should be more vigorously adhered to in patients with rheumatic mitral valve disease and LA thrombi.

Background: Coronary fistula is a congenital anomaly resulting in steal phenomenon of coronary blood flow, which may result in clinical symptoms and/or signs of coronary artery disease (CAD), including angina pec-toris, myocardial ischemia, and congestive heart failure. The purpose of this study is to do a retrospective analysis of myocardial ischemia in 201 Tl images in patients with coronary fistulae. 26,758 cases underwent coronary angiography in our hospital and 58 of them (0.22%, 32 male; mean age 62 ± 14, range from 35 to 87 years old), with chest pain and/or chest tightness underwent stress test for CAD. All patients received dipyridamole as pharmacological stress. All patients were followed by image acquisitions done immediately after stress and 4 h later. Results: All patients revealed coronary fistula by coronary angiography. Origin, drainage site, and diameter (large fistula ≥ 10 mm, small fistula < 10 mm) of each fistula were recorded. Fifty seven patients (98%) had 201 Tl perfusion defects in either reverse [R], partial reverse [PR], or reverse redistribution [RR] patterns. In the 201 Tl SPECTs, 82 abnormal perfusion areas were found including 52R (63%), 21PR (26%), and 9RR (11%). In all coronary fistulae, 64% (28/44) in LAD could see 201 Tl perfusion defects in anterior, septal, and/or apical areas. In addition, 71% (5/7) in LCX could detect defects in lateral or inferior areas, and 70% (14/20) in RCA could detect defects in inferior and/or lateral areas. In fistulae without 201 Tl perfusion defect in corresponding territories, micro-fistulae were noted in 81% (13/16) of fistulae in LAD, 100% (3/3) of fistulae in LCX, and 83% (5/6) of fistulae in RCA. Conclusions: Myocardial ischemia with abnormal 201 Tl perfusion image can be detected in large portion of patients with coronary fistulae. Coronary fistulae with ischemia in 201 Tl perfusion images also can be associated with chest pain and/or chest tightness. The absence of 201 Tl perfusion defect in patients with coronary fistula may be due to micro-fistula without evident steal phenomenon of coronary blood flow.