Abstract We present a patient with chest pain and suspicious findings in electrocardiography and myocardial perfusion scintigraphy for myo- cardial ischemia. Coronary angiography and then echocardiography and magnetic resonance imag- ing revealed a dilated left anterior descending coronary artery, which has fistulous communica- tion with a large, separate chamber that occupies the infero-apical interventricular septum. This is a challenging congenital anomaly for a clinician in many aspects, which are discussed in the report. Keywords Congenital heart disease Æ Coronary anomaly Æ Coronary fistula Introduction Coronary artery fistulas are rare congenital abnormalities that occur in 0.12% of patients who underwent coronary angiography [1]. Usually these fistulas drain into one of the cardiac cham- bers or veins. Rarely, these fistulas may be accompanied by additional congenital abnormal- ities. We present a dilated left anterior descend- ing (LAD) coronary artery which has a fistulous communication with a separate, additional chamber of the heart in a middle-aged man with suspected coronary artery disease. Case report A 57-year-old man was referred to our cardiology department for coronary angiography due to squeezing retrosternal chest pain with exercise for 2 months. He had exercise myocardial perfusion scintigraphy (MPS) with thallium performed 2 months ago that revealed a fix defect in the in- feroseptal wall of left ventricle and no additional ischemic changes (Fig. 1A). He had no coronary risk factors except smoking. On physical exami- nation, his blood pressure was 120/80 mmHg and heart rate was 76 b.p.m. A mild systolic murmur at the mezocardiac region was detected. Electrocar- diography (ECG) showed T wave inversion at anterior and inferior leads (Fig. 1B). In coronary angiography, right and left circumflex coronary arteries were normal. But, left main and LAD coronary arteries were abnormally dilated (Fig. 2). Flow pattern of this vessel was diastolic slow flow and systolic back-flow. The LAD coro- nary artery was terminating with a fistulous communication into a distinct structure at the apex O. Badak Æ B. Akdeniz Æ O. Goldeli Department of Cardiology, School of Medicine, Dokuz Eylul University, 35340 Inciralti, Izmir, Turkey O. Badak (&) K. Dirik M., 220/1 S., Ozboran Apt. B Blok, No: 4, D:5, 35100 Bornova, Izmir, Turkey e-mail: ozer.badak@deu.edu.tr Int J Cardiovasc Imaging (2006) 22:785–789 DOI 10.1007/s10554-006-9115-6 123 CASE REPORT Five chambered heart: a case report and brief review of literature Ozer Badak Æ Bahri Akdeniz Æ Ozhan Goldeli Received: 8 May 2006 / Accepted: 29 May 2006 / Published online: 20 June 2006 Ó Springer Science+Business Media B.V. 2006