J Cardiol 2007 Sep; 50（3）: 193– 197

Right Coronary Artery to Left
Ventricle Fistula Associated With
Three-Vessel Coronary Artery
Disease : A Case Report
Hidehiko ARAKI, MD
Michiya KAGEYAMA, MD
Shu INAMI, MD
Isao TAGUCHI, MD
Shichiro ABE, MD
Ryuko MATSUDA, MD
Yoshihiko MOCHIZUKI, MD＊1
Noboru KANEKO, MD, FJCC
Abstract ─────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────
Right coronary artery to left ventricle fistula is a rare type of coronary artery fistula among congenital
coronary artery anomalies. Most patients exhibit no symptoms and some experience chest pain. Coronary
angiography sometimes detects the presence of coronary artery fistula, but not coronary arteriosclerosis. A
76-year-old man with unstable angina was admitted because he did not respond to drug therapy. Coronary
angiography showed three-vessel coronary artery disease and the contrast agent entered the left ventriclefrom the terminal of the right coronary artery during diastole. Multidetector-row computer tomography
showed similar findings. The patient subsequently underwent coronary artery bypass grafting and obliteration of the coronary artery fistula. The chest pain was relieved and he is now in good condition.
──────────────────────────────────────────────────────────────────────────────────────────────────────────────────────J Cardiol 2007 Sep; 50（3）: 193 −197Key Words■ Coronary artery disease（coronary ventricular fistula, three-vessel disease）■ Interventional cardiology（coronary artery bypass grafting）■ Computed tomography（multidetector-row）

INTRODUCTION
Coronary ventricular fistula is an anomalous
anastomosis in which the coronary blood flows
directly into the ventricle without running throughthe ventricular capillaries. This condition is now
reported more frequently due to advanced cardiac
catheterization tests. Right coronary arterial flow
into the ventricle was found in 3 of 31 patients（9.7%）with coronary ventricular fistula. 1） An
opening in the left ventricle was found in 11 out of

363 patients（ 3%）. 2）The incidence of ventricle
openings has varied considerably in previous studies, and in many patients there are multiple sites of
opening and flow. However, the right coronary
artery opens more frequently into the right heart,
not the left ventricle,1,2）and right artery-left ventricular fistula was a rare coronary artery anomaly
in 126,595 patients undergoing coronary angiography.3）
Coronary ventricular fistula can be diagnosed bycoronary angiography, but some cases are difficult──────────────────────────────────────────────
獨協医科大学 心血管・肺内科，＊ 1 胸部外科 : 〒 321−0293 栃木県下都賀郡壬生北小林 880
Department of Cardiology and Pneumology, ＊ 1Department of Cardiothoracic Surgery, Dokkyo Medical University School of Medicine,Tochigi
Address for correspondence : MATSUDA R, MD, Department of Cardiology and Pneumology, Dokkyo Medical University School ofMedicine, Kitakobayashi 880, Mibu, Shimotsuga-gun, Tochigi 321−0293 ; E-mail : ryukom@dokkyomed.ac.jp
Manuscript received April 16, 2007 ; revised May 26, 2007 ; accepted June 9, 2007193

194

Araki, Kageyama, Inami et al

Fig. 1 Coronary angiograms and multidetector-row computer tomography scan
Selective left coronary arteriography showed diffuse atherosclerotic lesion in the proximal left anterior
descending artery with branch lesions and multiple stenotic lesions in the left circumflex artery（A）.
Selective right coronary angiography in diastole showed multiple stenotic lesions in the right coronary
artery and the coronary fistula（arrows）with the contrast agent draining into the left ventricle（B）. Coronary
angiography in systole showed fistulous coronary vessel（arrows）compressed during myocardial contraction（C）. Multidetector-row computer tomography showed the fistulous right coronary artery（arrows）. The
left ventricle also exhibited opacity（D）.
LV ＝ left ventricle.

to detect. Here, we report a patient with unstableangina and right coronary artery to left ventricle fistula associated with three-vessel coronary arterydisease detected by coronary angiography and multidetector-row computed tomography（ MDCT）.
The patient underwent obliteration of the coronary
artery fistula and coronary artery bypass grafting（CABG）.
CASE REPORT
A 76-year-old male was admitted to our hospitaland complained of exertional chest pain that continued at rest. He underwent coronary angiography inanother hospital and three-vessel coronary arterydisease was found. He was treated with nitrates, acalcium channel blocker, and a β-blocker, but thesymptoms aggravated and the patient underwent
detailed examination in our hospital. He had noprevious illness or significant family history. On thefirst visit, no heart murmur was detected and chest
radiography, ECG and blood tests showed noabnormal findings. Echocardiography indicatedgood left ventricular function and normal wallmotion. No abnormal color flow signal was shown.
Second coronary angiography found 50% to 90%
stenoses and diffuse atherosclerotic lesion at several sites of the left anterior descending and circumflex arteries（Fig. 1−A）. Diffuse atherosclerosis
was also observed throughout the right coronary
artery and no collateral coronary flow was found.
Furthermore, the contrast agent flowed into the left
ventricle from the slightly dilated peripheral rightJ Cardiol 2007 Sep; 50（3）: 193– 197

Coronary Fistula With Three-Vessel Diseasecoronary artery during diastole（Fig. 1−B, arrows）,
and from the fistulous coronary vessel in the compressed myocardium during systole（ Fig. 1−C,arrows）. MDCT showed the peripheral posterolat-195

eral branch of the right coronary artery ascending
the posterior interventricular branch and connecting
directly to the upper left ventricular posterior wall,
because the contrast agent filled the left ventricle（Fig. 1−D）. MDCT confirmed the communication
between the right coronary artery and the left ventricle.
The patient underwent ligation of the coronary
artery fistula and CABG. During surgery, the fistulous artery was found in the myocardium andexposed. The opening of the coronary fistula wasobserved in the initial part of the posterior interventricular branch at the base of the left ventricularposterior wall（Fig. 2）. After surgery, the contrast
agent did not flow into the left ventricle from theperipheral right coronary artery during diastole（Fig. 3−A）, and coronary blood flow through thegraft was good without blood flow from the rightcoronary artery to the left ventricle（Fig. 3−B）.
The chest pain was relieved and the patient is now
in good condition.
DISCUSSION

Fig. 2 Intraoperative photographSurgical findings showed a right coronary artery draining into the left ventricle. The arrow indicated theexposed fistulous vessel.
RCA ＝ right coronary artery.

Coronary ventricular fistula is sometimes foundin infants and children during examinations forcongenital heart disease and heart murmur. 4−6）
Huge fistula, dilated coronary artery, and aneurysm
formation can appear as cardiac hypertrophy on

Fig. 3 Coronary angiogram and multidetector-row computer tomography scan after operation
Selective right coronary arteriography after surgical treatment showed obliteration of the anomalousdrainage（A）. Multidetector-row computer tomography after the operation for fistula ligation and coronary
artery bypass grafting demonstrated the patency of the coronary bypass grafts（B）.
LITA ＝ left internal thorax artery ; LAD ＝ left anterior descending artery ; SVG ＝ saphenous vein graft ;LCX ＝ left circumflex artery. Other abbreviation as in Fig. 2.

J Cardiol 2007 Sep; 50（3）: 193– 197

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Araki, Kageyama, Inami et alchest radiographs in cases of right coronary arteryto left ventricular fistula.7,8）In many cases of chest
pain, there is no evidence of coronary arteriosclerosis,4,9−12）even in patients with myocardial infarction.13,14）Some cases of dilated fistulous coronary
artery were found by coronary angiography.8,15）
Coronary spasm unrelated to the fistula wasobserved in one patient.10）Myocardial ischemia ofcoronary ventricular fistula is likely to be due toshunting of blood flow and the so-called steal
phenomenon.10−12）
The current patient exhibited no heart murmur.
Abnormal shadow and cardiac hypertrophy onchest radiographs were not observed. This patientcomplained of chest pain at rest and the diagnosis
was unstable angina pectoris due to three-vessel
coronary disease associated with right coronary
artery to left ventricular fistula. As this condition
was unresponsive to drug treatment, surgical
CABG and ligation of the fistula were performed.
The severity of the coronary arterial lesions may
have led to aggravation of the symptoms and thelack of response to medical treatment, but any relationship between the coronary ventricular fistulaand the occurrence of angina pectoris was not clear.
However, no significant electrocardiogram change
and chest pain were observed after ligation of thecoronary artery fistula.
Selective coronary angiography is generally very
要

useful as a diagnostic method for coronary ventricular fistula. Recently, echocardiography, especiallycolor Doppler flow mapping,1,15）and MTCT8）havealso been used for confirmation. In this case, thediagnosis was established by coronary angiography
and confirmed by MDCT, but was not indicated by
two-dimensional imaging with color Doppler flow
mapping. In this case, MDCT and selective coronary angiography were useful to confirm the location and size of the coronary artery-left ventricle
fistula.
Medical treatment options include nitrates, calcium channel blockers and β-blockers. However,drugs may enhance the steal phenomenon and may
not improve myocardial ischemia.12）Surgical treatment, including ligation of the coronary artery andfistula obliteration, can be performed to prevent
aortic valve regurgitation-like hemodynamics, congestive heart failure, infectious endocarditis, thrombosis, arrhythmia and sudden death. 4,6,15） Our
patient did not respond to drug therapy due to thesevere coronary lesions, so underwent simultaneous
obliteration of the coronary artery fistula andCABG. Postoperative coronary blood flow wasgood due to open grafts, myocardial ischemia was
improved, and chest pain was relieved. This treatment has improved the patient s quality of life andincreased his social activities, and we continue withthe follow-up.
約

冠動脈 3 枝病変を伴った右冠動脈左室瘻の 1 例
荒木秀彦

景山倫也

伊 波秀

田 口功

阿部七郎

松田隆子

望月吉彦

金 子

昇

右冠動脈左室瘻は先天性冠動脈異常の中でもまれである．多くの患者は無症状であるが，胸痛を訴え，冠動脈造影検査でときどき冠動脈瘻を発見されることがあるが，冠動脈病変は認められない．
我々は，冠動脈 3 枝病変を伴った右冠動脈左室瘻で冠動脈グラフト術と冠動脈瘻閉塞術を施行した症例を報告する．症例は 76 歳，男性，不安定狭心症で薬剤が無効で増悪したため入院した．冠動脈造影検査所見は，高度び漫性動脈病変を呈する 3 枝病変で，また拡張期に右冠動脈房室結節動脈末梢部がやや拡張し，造影剤が房室間側壁付近から左室あるいは左房へ流入する所見を得た．収縮期にはこの血管は圧縮され確認できなかった．マルチディテクターコンピューター断層撮影で右冠動脈末梢部にやや拡張した血管と左室の造影を認めた．冠動脈 3 枝病変を伴った右冠動脈左室瘻と診断し，冠動脈グラフト術および右冠動脈瘻閉塞術を施行した．術後，胸痛は消失し経過良好である．

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J Cardiol 2007 Sep; 50（3）: 193– 197

Coronary Fistula With Three-Vessel Disease

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