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Variant angina of Prinzmetal has been generally presumed to be caused by a significant focal obstruction in a single major coronary artery which should be an ideal lesion for aortocoronary saphenous vein bypass graft. Recognition of this clinical syndrome would then be of particular diagnostic and therapeutic importance if such a consistent association can be demonstrated. Of five patients with variant angina studied in our cardiac catheterization laboratories, four had normal coronary arteriograms. Two important conclusions may be derived from this study. First, identical ECG changes may be observed both in the presence and absence of pain and thus the incidence and severity of the variant angina could be underestimated. Second, until a larger series of patients with variant angina is studied by coronary arteriography, one must exercise reservation in assuming that all patients with the clinical syndrome are operative candidates for saphenous vein bypass surgery.

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A 22-year-old female with cyanotic congenital heart disease was found to have veno-arterial shunting via a large secundum atrial septal defect despite normal pulmonary arterial and right ventricular pressures. Persistence of the Eustachian valve of the inferior vena cava was suspected preoperatively and confirmed at operation. This valve caused a large right-to-left shunt by favoring the flow of inferior vena caval blood into the left atrium via the defect. Surgical excision of the abnormal valve and closure of the atrial septal defect resulted in complete physiological and clinical cure.