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Coronary artery fistulas (CAFs) are rare congenital heart diseases in which there is a communication between a coronary artery and a cardiac chamber or a great vessel. Its diagnosis can be made noninvasively by echocardiography. We report a case of left anterior descending coronary artery (LAD) to right ventricle fistula where the diagnosis was made by 2D and Doppler echocardiography. The fistula was an incidental finding in an asymptomatic 5-year-old child who underwent echocardiography because of a loud cardiac murmur on physical examination. The Doppler study allowed to accurately evaluate the haemodynamic consequences of the fistula. With this case report, we want to highlight how the typical flow pattern of a left coronary artery to RV fistula can be studied by a comprehensive Doppler echocardiography examination. The knowledge of the Doppler appearance in these cases can help to appreciate the pathophysiology of the fistula and to differentiate between other concomitant abnormalities such as muscular ventricular septal defects (VSDs).

Background Reduced physical performance and impaired mobility are common in elderly patients after acute coronary syndrome (ACS) and they represent independent risk factors for disability, morbidity, hospital readmission and mortality. Regular physical exercise represents a means for improving functional capacity. Nevertheless, its clinical benefit has been less investigated in elderly patients in the early phase after ACS. The HULK trial aims to investigate the clinical benefit of an early, tailored low-cost physical activity intervention in comparison to standard of care in elderly ACS patients with reduced physical performance. Design HULK is an investigator-initiated, prospective multicenter randomized controlled trial (NCT03021044). After successful management of the ACS acute phase and uneventful first 1 month, elderly (≥70 years) patients showing reduced physical performance are randomized (1:1 ratio) to either standard of care or physical activity intervention. Reduced physical performance is defined as a short physical performance battery (SPPB) score of 4–9. The early, tailored, low-cost physical intervention includes 4 sessions of physical activity with a supervisor and an home-based program of physical exercise. The chosen primary endpoint is the 6-month SPPB value. Secondary endpoints briefly include quality of life, on-treatment platelet reactivity, some laboratory data and clinical adverse events. To demonstrate an increase of at least one SPPB point in the experimental arm, a sample size of 226 patients is needed. Conclusions The HULK study will test the hypothesis that an early, tailored low-cost physical activity intervention improves physical performance, quality of life, frailty status and outcome in elderly ACS patients with reduced physical performance. Trial registration Clinicaltrials.gov, identifier NCT03021044, first posted January, 13th 2017. Electronic supplementary material The online version of this article (10.1186/s12872-018-0839-8) contains supplementary material, which is available to authorized users.