Coronary steal resulting from LIMA-to-SVG-to-LAD-to-ventricular fistula physiology associated with malpositioned prosthetic aortic valve

Following aortic valve replacement (AVR) and a single vessel bypass (SVG) to the left-anterior descending artery (LAD), the patient had a non-ST segment myocardial infarction with graft occlusion and underwent left internal mammary artery (LIMA) to SVG to LAD. When we evaluated her at our institution for ischemic symptoms, we were able to determine the probable sequence of events and the reason for her symptoms. Her AVR was interfering with normal flow into the left main with associated coronary steal from the distal LAD. The AVR had to be revised and the patient's symptoms improved.