Demonstration of exercise-induced myocardial ischemia in a case of multiple coronary arterioventricular fistulas

Abstract

We report herein a case with multiple coronary arterioventricular fistulas, in which exercise-induced myocardial ischemia was demonstrated by stress thallium scintigraphy, illustrating the coronary “steal” phenomenon. A 52-year-old Japanese man complained of exertional chest pain for 1 year. The chest pain was relieved by rest but not by sublingual nitroglycerin or oral isosorbide dinitrate. His past medical history and family history were not contributory. Physical examination revealed blood pressure or 100/60 mm Hg and regular heart rate of 80lmin. There was no heart murmur. The chest x-ray examination showed slight cardiac dilation with cardiothoracic ratio of 52 % . The ECG showed T wave inversion in leads II, III, aVr, and V,.,. He complained of chest pain at peak treadmill exercise, along with pseudonormalization of T waves in leads II, III, aVr, and V,.,. Thallium-201 emission computed myocardial tomography at rest showed a mild perfusion defect of the inferoposterior to lateral wall of the left ventricle (LV) and posterior half of the septum, where severe perfusion defect was induced by peak ergometer exercise, with chest pain and pseudonormalization of T waves in leads II, III, aVr, and V,, (Fig. 1). Cardiac catheterization showed normal right and left heart pressures and no evidence of an intracardiac shunt. Left ventriculography revealed normal cavity size and no wall motion abnormality. Selective coronary arteriography showed no stenotic lesions and multiple fistulas from all three major coronary arteries (Fig. 2). The coronary venous drainage was normal. Propranolol therapy was started at oral doses of 90 mg/day and the frequency of exertional angina decreased. Although coronary artery fistula is an unusual congenital anomaly, clinical experiences have accumulated along with the evidence of selective coronary arteriography. However, the majority of coronary artery fistulas drain into the right heart chamber from a single coronary artery. Multiple coronary artery fistulas communicating with the LV involving all three major coronary arteries are extremely rare, and only five cases have been reported in the world literature.‘-5