CORONARY-ARTERY PULMONARY-ARTERY FISTULA ORIGINATING FROM 3 MAJOR CORONARY BRANCHES ASSOCIATED WITH EXERTIONAL CHEST PAIN AND TACHYCARDIA-DEPENDENT LEFT-BUNDLE-BRANCH BLOCK

A 49-year-old male was admitted to our hospital because of chest pain. The pain occurred simultaneously with tachycardia-dependent left bund le branch block (LBBB) during exercise-stress and atropine-stress elec trocardiogram (EGG) and on 24-h ambulatory ECG monitoring. Myocardial perfusion and metabolic scintigraphy with Tl-201 and I-123 BMIPP, resp ectively, showed no evidence of ischemia. Coronary arteriography revea led no atherosclerotic lesions, but did show a fistula between three m ajor coronary arteries and the main pulmonary artery. The left-to-righ t shunt was undetectably small. Administration of diltiazem and metopr olol suppressed LBBB by attenuating the heart rate response to exercis e, and reduced the chest pain. Therefore we presume that the exertiona l chest pain was not caused by myocardial ischemia but by the tachycar dia-dependent LBBB. Coronary artery-pulmonary artery fistula is the mo st common type of coronary artery fistulae found incidentally in adult hood. Involvement of three major coronary branches is, however, rare. The case is discussed with a review of the literature.