Coronary artery disease in aortic stenosis: importance of coronary arteriography and surgical implications.

In our report, the presence or absence of angina pectoris did not predict the presence of coronary artery disease. A significant number of patients with aortic stenosis and angina pectoris have coronary artery disease but coronary artery disease also exists in asymptomatic form in a significant number of patients with severe aortic stenosis that could not be detected clinically and therefore suggests that the routine use of selective coronary arteriography is indicated in patients over 40 years undergoing cardiac catheterization because of aortic stenosis. This is very important in the preoperative evaluation and in planning the technique of operation to employ during extracorporeal circulation and in determining the necessity of combining aortic valve replacement and myocardial revascularization.

Anomalous origin of the right coronary artery from the pulmonary artery with large left-to-right shunt (anomalous right coronary artery).

A coronary arteriovenous fistula was diagnosed in a 20-year-old white male because of a continuous murmur atypically located along the left sternal border. Cardiac catheterization revealed a large left-to-right shunt, and selective coronary arteriography established the precise anatomic diagnosis. The patient was treated successfully by surgical reimplantation of the anomalous coronary artery into the aorta and ligation of its origin at the pulmonary artery. The embryological and clinical features of this anomaly are discussed, and mechanisms for its production are suggested. Attention is called to our observation of an apparent male sex predilection of this anomaly from review of the literature, in addition to the present patient. This is apparently the fourth patient with this anomaly whose condition was diagnosed antemortem by selective coronary arteriography and the fourth to have been treated by aortocoronary anastomosis providing an additive supply for both the present and the future. This is also the second case in the literature to have the transplanted right anomalous coronary artery demonstrated by selective coronary arteriography. It is likely that, with increasing use of selective coronary arteriography inthe diagnostic work-up of cardiac patients, more cases will be discovered and treated surgically.

Surgical closure of left coronary artery-left ventricular fistula: the second case reported in the literature and a review of the five previously reported cases of coronary artery fistula terminating in the left ventricle.

Surgical closure of a left coronary artery-left ventricular fistula in a 44-year-old black man is reported. The fistula was discovered by coronary arteriography after the patient was admitted to the hospital complaining of recurrent chest pain. The fistula was closed with cardiopulmonary bypass, ischemic arrest, and hypothermia, and there was an uneventful postoperative recovery. The previously reported five cases of fistulas terminating in the left ventricle that were closed surgically are reviewed. Four of these cases originated in the right coronary artery and one in the left coronary artery. Three of the six patients were symptomatic at the time of discovery of the lesion. Cardiopulmonary bypass was necessary in five of the six cases. One patient died in the postoperative period from intractable hemorrhage. It is recommended that coronary artery fistulas by closed upon establishment of the diagnosis because of the sequelae if they are allowed to remain open; these include premature atherosclerosis, aneurysmal dilatation of the coronary artery, and congestive heart failure.