A case of a right coronary artery to left ventricle fistula observed over twenty years.

Since the natural history of a coronary artery to left ventricle fistula is not well known, a case of such a fistula in 36-year-old female patient, followed for 20 years is presented. Two-dimensional echocardiography performed as a follow-up examination revealed enlargement of the right coronary artery and the right Valsalva sinus. Two-dimensional color flow mapping showed the jet flow to the apex from the base of the left ventricle only during the diastolic phase. An aortogram confirmed that enlargement of both the right coronary artery and the right Valsalva sinus had occurred during the 20 years. The shunt flow ratio was about 50%. The Symbas procedure, closing of the coronary artery fistula by arteriotomy directly over the site of the fistula, was performed with the aid of extracorporeal circulation. Our findings indicate that enlargement of the shunted coronary artery and its Valsalva sinus can occur gradually where there is a relatively large shunt flow. Therefore, early surgical treatment is recommended in cases like this one.