P157 THE UNFORESEEABLE LINK: A CASE OF CORONARY–PULMONARY ARTERY FISTULA BRIDGING THE RIGHT CORONARY AND FIRST SEPTAL BRANCH OF THE LEFT ANTERIOR DESCENDING ARTERY

Abstract

Abstract Coronary–pulmonary artery fistulas are a rare clinical entity with a variety of potential clinical manifestations. Albeit rare, such anomalies may in some instances involve multiple coronary arteries and go unnoticed until old age producing little to no clinical manifestations. We hereby present the case of an 83–year–old man, heavy smoker, with a history of cor pulmonale due to severe chronic obstructive pulmonary disease (COPD) who was recently diagnosed with metastatic lung adenocarcinoma. Incidentally, one of the ECGs performed revealed negative T waves in the precordial leads in the absence of symptoms and with a negative troponin curve. Echocardiography was thus performed and revealed severe left ventricular systolic dysfunction (EF 31%) with infero–postero–lateral akinesia. The patient underwent CT coronary angiogram, which ruled out any significant coronary stenosis but revealed a most surprising finding. An ectatic arterial branch running anteriorly and draining into the pulmonary artery connected the the proximal segment of the right coronary artery to the first septal branch of the left anterior descending (LAD) artery. Unfortunately, the severe left ventricular failure contraindicated any chemotherapy and the patient was discharged with a plan to start palliative radiotherapy. Three months later, the patient returned to our Hospital due to worsening weakness, cachexia and one episode of pre–sincope. During this hospital stay, he developed atypical chest pain with a significant troponin curve. A HRCT and pulmonary angiogram was performed, which revealed neoplastic progression with bilateral lung involvement and bone metastases, as well as bilateral segmental pulmonary emboli. Echocardiography demonstrated new segmental areas of akinesia (apical septum and mid–apical anteroseptal segment) suggestive of focal ischemic damage. Given the documented pulmonary embolism and the anomalous connection between pulmonary artery and coronary circulation, this event may have been caused by paradoxical embolism travelling from pulmonary to coronary circulation (most likely affecting the LAD artery territory). Due to the patient’s frailty however, this hypothesis could not be confirmed by coronary angiography. Despite their relative rarity, coronary–pulmonary artery fistulas involving multiple coronary arteries can occur in the elderly population with no previous clinical manifestations and may give rise to apparently unfathomable clinical constellations.