No abstract

A 65-year-old woman presented with intermittent left bundle branch block and angina pectoris. Cardiac catheterization demonstrated bilateral coronary artery fistulae entering diffusely into the left ventricle without evidence of major arterial-luminar shunt. A surgical procedure to reduce the arterial-to-cameral flow is discussed, and case reports are reviewed and discussed.

There have been many angiographic and necropsy reports focusing on left main coronary artery disease of greater than 50%.1-8 The degree of peripheral coronary disease in patients with this specific lesion is impressive. Bulkley et a1.9 reported a necropsy analysis of 152 patients with left main lesions. Thirtyfive patients had greater than 75% narrowing of the left main coronary artery, and 30 patients had 50 to 75% narrowing of the left main coronary artery. Of these patients, all had at least one other significantly involved vessel, and the majority of them had severe three-vessel coronary artery disease. The overall incidence of isolated left main disease in a combined analysis was 4%.9 Because of these data, it is tempting to diagnose single obstructions of the left main coronary artery without peripheral involvement as coronary artery spasm10,ll rather than as obstructive coronary artery disease.Over the last year and a half, in a large community hospital, we studied 38 patients with left main coronary artery stenosis. Of these patients, we found 2 with isolated fixed left main coronary artery stenosis (5.2%). In both cases there was skepticism about the absence of distal coronary involvement. However, at surgery both patients demonstrated palpable atherosclerotic lesions at the origin of the left main coronary artery, with no evidence of significant atherosclerotic involvement of the peripheral coronary vessels. Case 7A 52-year-old white woman had a hisLory of atypical chest pain for I 8 months before her initial hospitalization. This right-sided discomfort radiated to the right shoulder and back. The pain was atypical of angina in that it lasted at times for 45 minutes and was infrequently associated with exertion.We initially saw the patient in the hospital because of these complaints, and because of an abnormal electrocardiogram with repolarization changes over the anterior precordial leads. The patient underwent treadmill testing which was strongly positive in that her exercise performance was poor. Following exercise she became hypotensive and suffered prolonged chest pain. Coronary arteriography demonstrated left main coronary artery stenosis, which was partially relived following administration of nitroglycerine (90 to 75%) (Figure 1 ). No significant distal coronary disease was noted (Figure 2).