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Congenital coronary arteriovenous fistula is an uncommon anomaly. Steinberg et al. (1958) reviewed 21 cases and added one of their own. The majority of the patients were asymptomatic. However, three deaths due to cardiac failure consequent upon the fistula were recorded. Gasul et al. (1960) reported five cases, four of which were successfully operated upon. The diagnosis was suspected and proved pre-operatively in three of the five. Fourteen other fistulae have been closed satisfactorily (Gasul et al., 1960;Lam et al., 1960;Amplatz et al., 1960). This paper describes the caser of a symptomatic 4-year-old white girl in whom the diagnosis was suspected clinically and proved by cardiac. catheterization and retrograde aortography.The abnormal left circumflex coronary artery was surgically ligated and she has been completely asymptpmatic since her operation two and a half years ago. Cae ReportA 3+-year-old white girl was first seen on November 13, 1957, for assessment of a heart murmur, which had been noted one month previously during a bout of influenza. After this latter illness, breathlessness on exertion became evident for the first time. Her past history and family history were non-contributory.Physical examination revealed a small, fairly well nourished child-weight 13.5 kg. (10th percentile) and height 94 cm. (10th percentile) Cyanosis and-clubbing were not evident. There were no signs of congestive cardiac failure. The pulse was collapsing in quality and the blood-pressure in the right arm measured 80/30 mm. Hg and in the right leg 124/40 mm. Hg. The heart was not clinically enlarged. It was overactive and a left ventricular apical impulse was noted. A systolic thrill was felt in the xiphisternal region and along both sides of the lower end of the sternum. The first heart sound was normal. The second heart sound was well split and moved normally on respiration, with both components of equal intensity. A continuous murmur grade 4/6 with systolic accentuation was audible in the tricuspid area. It radiated to the xiphisternum and lower left sternal border. At the apex a mid-diastolic murmur grade 1-2/4 was noted. The remainder of the clinical examination was essentially negative.Her electrocardiogram showed an rR' pattern in 4VR and rSr' in Vi. X-ray examination of the heart revealed a cardiothoracic ratio of 45%. No chamber enlargement was demonstrated, but the pulsation in the right atrium, pulmonary artery, and aorta was excessive. The lung vascularity was within normal limits.Phonocardiography confirmed the continuous murmur (Fig. 1). The duration of the second sound was 0.05 second. The differential diagnosis at this stage was: (1) coronaryartery/coronary-vein fistula, (2) coronary-artery/right-atrium fistula, (3) arteriovenous malformation of right internal mammary vessels, or (4) rupture of a sinus of Valsalva into the right atrium. Cardiac catheterization performed on November 21 revealed a left-to-right shunt of 4.7 I./min./m.' at atrial level (see Table below). All pressures on the right side of the ...

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