Optical Coherence Tomography Findings in an Acquired Coronary Fistula

Abstract

Most coronary artery fistulas (CAFs) have a congenital origin. Acquired CAF is a rare entity that may occur without an identifiable causative link. We present here the case of an acquired CAF in which optical coherence tomography was instrumental in outlining that its possible cause was a spontaneously ruptured, communicating, subadventitial coronary hematoma. A man aged 67 years was admitted for oppressive chest pain and sudden-onset dyspnea. He was a former smoker, had dyslipidemia and diabetes mellitus, and was in permanent atrial fibrillation. He also had had 2 mechanical valves implanted in the mitral and aortic positions in 1993 and 2003, respectively. No intervention in the tricuspid valve was performed. Before the second surgery, a coronary angiography revealed normal anatomy and the absence of obstructive atherosclerosis (Figure 1). At admission, he was normotensive and had mild signs of systemic congestion. A continuous soft murmur on the left sternal border was also heard. The ECG showed atrial fibrillation and a previously known complete left bundle-branch block with secondary ST-T changes. Transthoracic echocardiography showed normal function of both valves and of the left ventricle. Finally, the international normalized ratio was 4.0, and serial cardiac marker assays uncovered a rise in troponin I (peak, 5.29 U). Thus, myocardial infarction in the presence of a left bundle-branch block was diagnosed, and coronary angiography was scheduled. This …