Abstract
A 51-year-old woman with a history of chronic obstructive lungs disease and cor pulmonale was referred to our institution for stable angina pectoris. Coronary angiography did not show any atherosclerotic lesion, but left coronary angiography showed the presence of two small fistulae from both the left anterior descending artery and the left main coronary artery to the pulmonary artery and right coronary angiography showed significant contrast passing from the right coronary artery into the left superior pulmonary vasculature. The most prominent angiographic findings were the lack of competition between the flow from the fistulae to the pulmonary artery and the native pulmonary artery flow and the left pulmonary vascular bed was filled completely by the contrast agent (see Figure 1, panel A-B and online video 1). An anomaly of the pulmonary arterial system was suspected and multislice computed tomography was done. Interestingly, the tomographic images showed a filling defect in the left main pulmonary artery after the pulmonary bifurcation, which was compatible with partial pulmonary agenesis. (see Figure 1, panel C). Connections between the coronary arterial system and the pulmonary arterial vasculature are relatively uncommon.1 The most important characteristic of the pattern of flow dynamics of these fistulous connections between the coronary artery and pulmonary artery is the competition of fistulous flow with the native pulmonary artery flow. Angiographically, this competitive flow appears as dissolution of contrast agent in the pulmonary artery. In online video 2 (right panel), an angiographic image of a 28-year-old patient who had a fistula from the circumflex artery to the pulmonary artery, which is compatible with the fistulous characteristics mentioned above, is presented. In the literature, coronary to pulmonary collateral flow associated with pulmonary artery hypoplasia has been described previously.2 If the connection between the Coronary to pulmonary connection: fistula or collateral?
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