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An 85-year-old woman underwent transthoracic echocardiography for the investigation of breathlessness and atypical chest discomfort. Clinical examination was unremarkable. A standard 12 lead ECG demonstrated anterior T wave inversion, but was otherwise normal. Transthoracic echocardiography demonstrated a normally functioning left ventricle with hypertrophy and trabeculation of the apical and lateral segments. Imaging with colour flow Doppler demonstrated blood flow from the epicardial surface into the left ventricular cavity through the hypertrophied segment of myocardium during diastole. A diagnosis of multiple, diffuse coronary-left ventricular fistulae predominantly of a large diagonal branch of the left anterior descending artery was made at coronary angiography. The patient responded well to oral beta-blockade, reporting an improvement in symptoms 2 months later in the outpatient clinic. The echocardiographic appearances of coronary fistulae may cause diagnostic confusion, particularly in the presence of myocardial hypertrophy and trabeculation.