Left coronary artery-left ventricular fistula with acute myocardial infarction, representing the coronary steal phenomenon: a case report.

A 59-year-old man presented with a left anterior descending coronary artery to left ventricular fistula manifesting as myocardial infarction, representing the coronary steal phenomenon. Electrocardiography showed poor R progression in leads V1 through V3. The biochemical markers of myocardial injury were elevated. Creatine kinase level was 509 IU/l, creatine kinase MB isoenzyme (CK-MB)47 IU/l, cardiac troponin T 0.62 ng/ml, myosin light chain 6.1 ng/ml, and myoglobin 142 ng/ml. Thallium-201 myocardial perfusion imaging with dobutamine stress showed a dobutamine-induced perfusion deficit of the anteroseptal wall of the left ventricle with 0.1 mV ST-segment depression in II, III, aVF, V5, and V6. The mean left anterior descending blood flow measured with the Doppler guidewire was increased from 211 to 378 ml/min. Selective coronary arteriography showed dominant left coronary artery with the contrast medium streaming into the left ventricle via a maze of fine vessels from the distal left anterior descending coronary artery. No critical stenosis of the left anterior descending coronary artery was observed. Administration of acetylcholine 100 micrograms into the left coronary artery did not induce vasoconstriction of that artery. The fistula terminating in the left ventricle was ligated surgically and the patient became free of chest pain. Thallium-201 myocardial perfusion imaging with dobutamine stress revealed no perfusion deficit of the anteroseptal wall of the left ventricle. The presence of coronary steal phenomenon was detected by dobutamine stress myocardial imaging.