[Coronary hemodynamics in a patient developing chest pain in the middle age in congenital coronary-pulmonary fistula].

Recently reports of congenital coronary-pulmonary fistula have been increasing with the wide-spread use of coronary angiography. However, the cause of the angina sometimes seen as a chief complaint in coronary fistula has not been well demonstrated although it has been suggested that coronary steal phenomenon accounts for it. This report documented coronary hemodynamics in a patient who came to develop anterior chest pain in the middle age owing to congenital coronary-pulmonary fistula, measuring coronary flow before and after the fistula-closure operation. A 35-year-old woman suffered from a sudden onset of severe anterior chest pain in April, 1986. She was referred to our hospital on suspicion of ruptured aneurysm of Valsalva. Auscultation disclosed continuous murmur at 3 LSB, but no evidence of ruptured aneurysm of Valsalva was detected by echocardiography nor aortography. Coronary angiography showed both left and right coronary fistula into the stem of pulmonary artery and otherwise normal angiogram. Great cardiac vein flow (GCVF) measured with regional thermodilution method was 25 ml/min at rest (70 bpm) and 30 ml/min during rapid atrial pacing (150 bpm) before the operation, and 30 ml/min (78 bpm) and 58 ml/min (150 bpm) after the operation, respectively. Before the surgery, anterior coronary resistance (CRant) was higher than that in normal subjects at rest and remained almost steady during atrial pacing. After the surgery, CRant was still higher at rest but remarkably reduced during pacing of 150 bpm. These findings suggest that the gradual increase in peripheral coronary resistance for a long time may lead to the inducement of coronary steal in the middle-later age in patients with coronary fistula.