SESSION TITLE: Etiologies of Cardiovascular Disease Case Report PostersSESSION TYPE: Case Report PostersPRESENTED ON: 10/19/2022 12:45 pm - 01:45 pmINTRODUCTION: Coronary artery fistulas (CAF) are rare phenomena categorized under anomalies of the coronary artery vasculature. They are typically formed during birth as congenital anomalies and can also be caused after endovascular procedures. We present the case of a 42-year-old male who presented with a left main and right coronary artery fistula to the pulmonary artery.CASE PRESENTATION: A 42-year-old male with a medical history of hypertension presented to the emergency department with a chief complaint of chest pain. The patient reported that he began to experience this pain four days ago, and it is severe, substernal, pressure-like pain exacerbated with exertion and associated with shortness of breath and diaphoresis. He denied any other complaints. He admitted to smoking ten cigarettes daily for 20 years and stated his father had a history of heart attacks. High-sensitivity troponin was unremarkable, and EKG showed normal sinus rhythm, normal axis, with T wave inversions in leads 1 and aVL. The patient was placed in observation and underwent lexiscan sestamibi nuclear stress testing, which revealed a moderate reduction in counts involving the mid to apical inferior segment, which moderately reversed. The size of the defect was moderate suggestive of ischemia. A 2D Echocardiogram revealed a left ventricular ejection fraction of 40 to 45%, moderate concentric left ventricular hypertrophy. Subsequently, the patient was admitted to the telemetry floors and received a left heart catheterization with bilateral coronary angiography and left ventriculography. This study revealed a large fistula from the left coronary artery to the pulmonary artery and a large fistula from the right coronary artery to the pulmonary artery. The Right coronary, left main, left anterior descending, and ramus arteries had minimal irregularities. The distal left circumflex artery had about 70% to 80% disease. Cardiothoracic surgery was consulted who planned the patient to have an outpatient repair of his coronary artery fistulas. The patient was discharged to home with instructions for cardiac magnetic resonance imaging and close follow-up.DISCUSSION: CAF account for about 0.2% of coronary vascular anomalies. Invasive coronary angiography is the gold standard for diagnosis of CAF; however, computed tomography angiography, echocardiogram and cardiac magnetic resonance imaging, may aid in diagnosis. Coronary pulmonary artery fistulas (CPAF), which are fistulas involving the major coronary vessels and the pulmonary artery, represent a majority of the cases of CAF. When indicated, CAF may be repaired by either surgical or endovascular repair.CONCLUSIONS: CAF is a very rare cardiac anomaly with an incidence of about 0.002% in the general public and accounting for about 0.2% of all cardiac anomalies. The etiology of CAF can be either congenital or acquired, with most acquired cases being secondary to interventional procedures.Reference #1: Yun, G., Nam, T. H., & Chun, E. J. (2018). Coronary artery fistulas: Pathophysiology, imaging findings, and Management. RadioGraphics, 38(3), 688–703. https://doi.org/10.1148/rg.2018170158DISCLOSURES: no disclosure on file for Ibrahim Khaddash;No relevant relationships by Christoper MilletNo relevant relationships by Mazhar MustafaNo relevant relationships by Spandana NarvaneniNo relevant relationships by Sherif Roman SESSION TITLE: Etiologies of Cardiovascular Disease Case Report Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Coronary artery fistulas (CAF) are rare phenomena categorized under anomalies of the coronary artery vasculature. They are typically formed during birth as congenital anomalies and can also be caused after endovascular procedures. We present the case of a 42-year-old male who presented with a left main and right coronary artery fistula to the pulmonary artery. CASE PRESENTATION: A 42-year-old male with a medical history of hypertension presented to the emergency department with a chief complaint of chest pain. The patient reported that he began to experience this pain four days ago, and it is severe, substernal, pressure-like pain exacerbated with exertion and associated with shortness of breath and diaphoresis. He denied any other complaints. He admitted to smoking ten cigarettes daily for 20 years and stated his father had a history of heart attacks. High-sensitivity troponin was unremarkable, and EKG showed normal sinus rhythm, normal axis, with T wave inversions in leads 1 and aVL. The patient was placed in observation and underwent lexiscan sestamibi nuclear stress testing, which revealed a moderate reduction in counts involving the mid to apical inferior segment, which moderately reversed. The size of the defect was moderate suggestive of ischemia. A 2D Echocardiogram revealed a left ventricular ejection fraction of 40 to 45%, moderate concentric left ventricular hypertrophy. Subsequently, the patient was admitted to the telemetry floors and received a left heart catheterization with bilateral coronary angiography and left ventriculography. This study revealed a large fistula from the left coronary artery to the pulmonary artery and a large fistula from the right coronary artery to the pulmonary artery. The Right coronary, left main, left anterior descending, and ramus arteries had minimal irregularities. The distal left circumflex artery had about 70% to 80% disease. Cardiothoracic surgery was consulted who planned the patient to have an outpatient repair of his coronary artery fistulas. The patient was discharged to home with instructions for cardiac magnetic resonance imaging and close follow-up. DISCUSSION: CAF account for about 0.2% of coronary vascular anomalies. Invasive coronary angiography is the gold standard for diagnosis of CAF; however, computed tomography angiography, echocardiogram and cardiac magnetic resonance imaging, may aid in diagnosis. Coronary pulmonary artery fistulas (CPAF), which are fistulas involving the major coronary vessels and the pulmonary artery, represent a majority of the cases of CAF. When indicated, CAF may be repaired by either surgical or endovascular repair. CONCLUSIONS: CAF is a very rare cardiac anomaly with an incidence of about 0.002% in the general public and accounting for about 0.2% of all cardiac anomalies. The etiology of CAF can be either congenital or acquired, with most acquired cases being secondary to interventional procedures. Reference #1: Yun, G., Nam, T. H., & Chun, E. J. (2018). Coronary artery fistulas: Pathophysiology, imaging findings, and Management. RadioGraphics, 38(3), 688–703. https://doi.org/10.1148/rg.2018170158 DISCLOSURES: no disclosure on file for Ibrahim Khaddash; No relevant relationships by Christoper Millet No relevant relationships by Mazhar Mustafa No relevant relationships by Spandana Narvaneni No relevant relationships by Sherif Roman