Angina pectoris caused by ⟫coronary steal⟪ syndrome in coronary artery-to-left ventricle fistula

History and clinical findings: A 55-year-old female patient reported left-sided chest pain at rest as well as during exercise, which recurred during the last three years before admission. Cardiovascular risk factors included hypercholesterinemia and smoking. The physical examination of the patient was unremarkable. Investigations: The ECG at rest showed T-wave inversions in leads I, aVL, V-3-V-6 and ergometric exercise testing resulted in angina pectoris and descending ST-segments in leads V-3-V-6. Stress thallium 201 scintigraphy demonstrated a reversible perfusion deficit of the the anterior wall at peak exercise. The left ventricular angiogramm and echocardiogramm revealed normal end-diastolic dimensions and regular systolic contractions without signs of left ventricular hypertrophy. Selective coronary arteriography excluded hemodynamically relevant stenosis of the coronary arteries. A coronary artery fistula originating from a large, ectatic first diagonal branch with drainage into the left ventricle was observed. Treatment and course: Because the patient rejected interventional therapy she was treated conservatively and follow-up investigations 3 and 4 years after arteriography revealed unchanged clinical symptomatology. Conclusion: In this case a >>coronary steals<< phenomenon caused by the coronary fistula induced myocardial ischemia. Therefore if present congenital coronary anomalies have to be considered in patients with chest pain and normal coronary angiogramm.