Coronary Artery Fistulae Discovered during Presentation of a Patient Having Heart Failure due to Severe Aortic Stenosis

Abstract

Introduction. Coronary artery fistulae (CAF) are rare defects with abnormal communication between a coronary artery with either a cardiac chamber or another vascular structure, bypassing the myocardial capillary network. We report a rare multiple arterial coronary fistulae with drainage to the right pulmonary artery. Case Presentation. A 56-year-old male was brought to our hospital for work-up of severe aortic stenosis. Further evaluation revealed multiple CAF with abnormal drainage to the right pulmonary artery. He was discharged after aortic valve replacement and closure of the coronary fistula. Conclusion. This case demonstrates that patients with complex CAF and drainage to the right pulmonary artery can remain asymptomatic and diagnosed accidentally during cardiac imaging, presenting particular challenges in both medical and surgical treatment.

Figure 1

Echocardiography, continuous-wave spectral Doppler across the aortic valve showed severe aortic stenosis with mean gradient 70 mmHg and peak gradient 105 mmHg.

Figure 2

(a) Still-frame image of late filling of coronary angiogram to left system with selective engagment of the LAD showed LM fistula (black arrows) which join the fistuous vessel of the other coronary artery and then drainage to the right pulmonary artery (RPA). (b) Still-frame image of cornonary angiogram to left system with selective engagement of the LCX and LM fistula (black arrow) fistolous vessel fills from the LCX (red arrow). (c) Still-frame image of cornonary angiogram of the RCA shows the fistolous vessel fills from RCA. (d) The same injection with late filling shows the fistula drainge to RPA. LAD: left anterior descending. LCX: left cercumflex. LM: left main. RAC: right coronary artery. RPA:right pulmonary artery.

Figure 3

(a) Volume rendering CTA showed LM fistula joining the fistulous vessel of the other coronary arteries draining into the RPA. (b) Curved MPR showed the insertion point of the fistula at RPA. LAD: left anterior descending artery. LPV: left pulmonary vein. LA: left atrium.