Traumatic coronary artery fistulas are reported less often than other complications resulting from both penetrating and blunt trauma to the heart. We describe a 50-year-old man in whom the natural history of a traumatic coronary fistula is well documented. This patient, who was referred for evaluation and treatment of complications of a traumatic coronary artery fistula resulting from a shrapnel injury 31 years before admission to the hospital, had five cardiac catheterizations prior to undergoing definitive surgical repair. During this period, he progressed from being totally asymptomatic to having disabling angina and congestive heart failure. These symptoms developed even though the patient's left-to-right shunt remained constant; moreover, the symptoms appeared to develop secondary to a "steal" of myocardial blood flow from the uninvolved coronary arterial bed through tortuous collaterals. Based on this experience and supported by published reports of 25 other patients, we recommend that nearly all patients with traumatic coronary artery fistulas be considered as candidates for elective surgical repair in order to prevent the eventual development of serious and possibly life-threatening complications. Operative repair can be accomplished safely with excellent long-term results.