An uncommon coronary artery fistula

Abstract

Coronary fistulae are considered rare and potentially dangerous coronary anomalies [1–3], causing different symptoms depending on the severity of both the shunt and the coronary steal. Treatment should be reserved for patients with Qp/Qs N1.5 and/or signs of significant reduction of the coronary reserve [4,5]. Sometimes, coronary fistulae may have a very uncommon course and drainage that make their management problematic. A 65-year-old hypertensive man was admitted to our center for a routine cardiac catheterization and coronary angiography secondary to repeated episodes of chest pain. The echocardiographic evaluation showed moderate ipokinesia of the anterior region of the left ventricle; no impairment of the coronary reservewas evidenced by the ergometric test, but the test was clearly positive for symptoms. The left coronary angiography revealed a fistulous vessel, originating directly from the aortic wall slightly above the left main ostium, draining into both the middle left anterior descending coronary artery (LAD) and the pulmonary artery. A moderate stenosis of the LAD, beyond the drainage site of the fistula, was detected (Fig. 1A–B). The right cardiac catheterization failed to demonstrate any significant shunt through the fistulae (Qp/Qs=1.1). The patient was discharged under medical treatment. He was asymptomatic at the 3-month follow-up.