Single Coronary Ostium Branching into the Right and Left Coronary Artery and Draining into the Pulmonary Artery: A Case Report

Abstract

This is the case of a 38-year-old female diagnosed with chronic glomerulonephritis and on chronic hemodialysis who was admitted for worsening heart failure. Physical examination revealed a continuous murmur in the left parasternal border, which decreased with inspiration. A chest radiograph revealed an enlarged main pulmonary artery. Transthoracic echocardiogram revealed a dilated right coronary ostium and a continuous Doppler signal in the main pulmonary artery (MPA), indicative of a fistula draining into the MPA. A coronary angiogram and cardiac computed tomography angiogram revealed an absent left main coronary artery and a right coronary artery (RCA) giving rise to the left anterior descending artery (LAD) and left circumflex artery (LCx). An arteriovenous fistula from the LAD draining into the MPA was also noted. She was diagnosed with anomalous origin of the LAD and LCx from the RCA with a coronary arteriovenous fistula from the LAD, LCx and RCA to the MPA, and end-stage renal failure due to glomerulonephritis. Her heart failure and renal failure were managed with optimal medical therapy and continuous hemodialysis, respectively. Surgery was offered to ligate the arteriovenous fistula. This case represents a rare combination of coronary anomalies. Despite the rarity, such defects should be suspected among patients presenting with heart failure and a continuous murmur on examination.