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Anomalous communication between the coronary arterial tree and a cardiac chamber or great vessel was first described by Krause in 1865. To date more than 100 cases have been reported. The earlier papers consisted of descriptions of necropsies but in the past few years, the introduction of heart catheterization, intracardiac phonocardiography, and angiocardiographic techniques has enhanced the interest in these anomalies. Several cases have been diagnosed during life and corrected by operation.The purpose of this paper is to present a patient with an unusual form of coronary arteriovenous fistula: both coronary arteries gave rise to an anomalous branch opening into an aneurysmal mass which overlay the main pulmonary artery and communicated with it.Case Report A47-year-old man, previously working as a coal-miner, was admitted in February 1966 for evaluation of a cardiac murmur which had been known for 21 years. He had been entirely asymptomatic throughout his life. On physical examination, the pulse rate was 70 a minute and the blood pressure 120/90 mm. Hg. The arterial pulses were normal, with no sign of "run-off", and the jugular venous pressure was not raised. The first sound was soft and the second normally split. There was a continuous murmur best heard in the 2nd left interspace and radiating widely over the praecordium. This murmur was sharply diminished during the strain and early post-strain period of a Valsalva manoeuvre.The electrocardiogram showed a sinus rhythm and a slight delay in right ventricular excitation.The chest x-ray showed anthracosilicosis grade p2 (International Labour Office, 1959). The left ventricle was mildly enlarged and the ascending aorta appeared unfolded and dilated. There was no sign of pulmonary hyperaemia.The phonocardiogram confirmed the presence of a continuous murmur best recorded in the 2nd left interspace. The greatest amplitude was in late systole and early diastole. There was no gap between the systolic and diastolic phases of the murmur which rode over the second sound without interruption.At right heart catherization, the pressures were normal in the cardiac chambers, pulmonary artery, and wedge position. A significant increase in oxygen saturation (7%) was disclosed at pulmonary artery level. The leftto-right shunt was 1 -41 l./min./m.2, i.e. 40 per cent of the systemic output.Intracardiac phonocardiography, using an Allard-Laurens' micromanometer, showed a continuous murmur present only in a very limited area, 2 to 3 cm. above the pulmonary valve. The greatest intensity was recorded when the side-hole of the catheter was on or just below the valvular level. The murmur disappeared when the catheter was pulled back into the right ventricle or pushed further into the pulmonary artery.Retrograde aortography (Fig.) from the left femoral artery showed a moderate unfolding and dilatation of the ascending aorta. The coronary arteries were in normal position but grossly dilated. They each gave rise to a large anomalous branch which entered a cirsoid formation overlying the u...

Thirty-four elderly patients with right bundle-branch block and left axis deviation were studied vectorcardiographically utilizing the McFee-Parungao system. Atherosclerosis, arterial hypertension, angina pectoris, cardiac enlargement, and heart failure were common clinical features in this series. Moreover, intermittent advanced degree of atrioventricular block was present in 10 out of the 34 patients. The vectorcardiograms might be readily classified into two basic patterns, types A and B. In type A (19 cases), the frontal plane loop was open-faced. The initial vectors were directed anteriorly, inferiorly, and to the right. The mid-temporal vectors were located in the left postero-superior octant, and the late portion of the loop was inscribed anteriorly to the right with conspicuous conduction delay. Those vectorcardiographic features associate the characteristic patterns of left superior intraventricular block with complete right bundle-branch block. The type B vectorcardiograms (15 cases) demonstrated anterior clockwise loops in the horizontal plane and superior counterclockwise loops in the frontal plane. From a review of the published reports and from personal data, the authors assume that both vectorcardiographic patterns may result from an abnormal spread of excitation resulting from bilateral branch conduction disturbances.