Diffuse communications between both the left and right coronary arteries and the left ventricle were found in a 46-year-old man presenting with typical angina pectoris. Symptoms were reproducible on treadmill exercise and ST segment depression, and redistribution septal defects were documented on stress Thallium scintigraphy. Antianginal drugs were effective in treating the patient's symptoms. Only 13 patients with similar anatomy have been previously described. This report is the first to document reproducible objective evidence of ischemia in such patients. The literature is reviewed and possible mechanisms of ischemia and its treatment discussed.