A rare case of coronary artery fistula presented with acute myocardial infarction

Abstract

Coronary artery fistulas (CAFs): Are anomalous connections of the coronary arteries (CA) with major vascular structures or heart chambers. Most of CAFs are incidental findings during invasive coronary angiography (ICA) or computed tomography angiography (CTA). Many patients with CAFs are asymptomatic; only a minority has been associated with various clinical features and outcomes. We have reported a rare CAF complicated with acute myocardial infarction (AMI) in 43 years old female Patient who was admitted to our institution with a Diagnosis of Acute Infero-Posterior Myocardial Infarction (AMI). ICA and CTA showed a thrombosed CAF between left main coronary artery and right atrium with totally occluded left circumflex artery by a thrombus extended from the fistula. As there was a high risk associated with immediate intervention, the patient was kept on conservative management with a future plan of catheter-assisted or surgical closure. We have shown a rare case of CAF presenting with AMI that is unusual for such an anomaly, and have highlighted the role of CTA in the diagnosis and management of such rare disorder.

Keywords: Acute myocardial infarction; computed tomography angiography; coronary anomalies; coronary artery fistula.

Figure 1

Twelve leads electrocardiogram showed ST elevation in II, III, AVF, with a tall R wave and ST depression in pericardial leads suggesting acute inferior posterior MI

Figure 2

Coronary angiography (a) left anterior oblique view, aneurismal left main (LM), left circumflex coronary artery is not visible. (b) Aneurismal LM (star), fistula-like structure rising from distal LM coronary artery with no clear termination (black arrow)

Figure 3

Computed tomography coronary angiography. (a) Maximum intensity projection (MIP), showing the aneurismal dilatation of the left main (LM) coronary artery. (b) MIP image at the level of LM coronary artery and the ostium of LAD and left circumflex coronary artery (LCX) showing aneurismal dilatation of LM and occluded LCX from its ostium. (c) multi planner reformation (MPR) image, note the thrombosed fistula between LM and right atrium (RA). (d) MPR image, showing normal left anterior descending artery. (e) MPR image, note the occluded LCX artery at the ostium (arrow) by thrombus, mid and distal thromboses. (f and g) volume rendering images showing the three dimensional orientation of the anatomy and the course of the fistula and its connections to LM and RA