[Multiple congenital coronaro-left ventricular fistulas. Apropos of 7 cases]

Multiple congenital coronary-left ventricular fistulae (CLVF) are rare (4.5% of all coronaro-cardiac fistulae, the same incidence as isolated CLVF); data obtained from 7 personal and 25 previously reported cases, showed that this anomaly, is diagnosed at coronary angiography performed for anginal chest pains in 2 out of 3 cases; cardiac auscultation was usually normal but the basal ECG was pathological in 3 out of 4 cases; the electrical changes suggested myocardial ischaemia in 20 out of 24 cases. However, exercise stress testing was negative in 47% of cases. Multiple CLVF usually arose from the same artery (59%); the commonest artery involved was the left anterior descending (84% of the single artery fistulae and 100% in cases of multiple CLVF arising from more than one artery). The angiographic appearances of multiple CLVF were constant: images of "intracavitary rain". Associated ventriculographic abnormalities were uncommon but coronary atherosclerosis was observed in 15% of cases. The main differential diagnosis is that of CLVF secondary to intra-left ventricular thrombosis due to the development of neovascularisation of the thrombus from the underlying endocardium. The value of non-invasive investigations (2D echocardiography alone or coupled with pulsed Doppler) has not been shown in this type of coronaro-cardiac fistulae. Surgical correction was attempted in 3 cases, 2 of which had associated cardiac pathology justifying surgery. The presence of unequivocal coronary insufficiency due to CLVF was not demonstrated despite some suggestive clinical and paraclinical indicators.