A Case of Coronary Cameral Fistula: When and How to Intervene?

Abstract

Coronary artery fistulas constitute a rare anomaly defined as an abnormal communication between a coronary artery and a great vessel or any cardiac chamber. The majority of these fistulas arise from the right coronary artery and the left anterior descending coronary artery; the circumflex coronary artery is rarely involved. We present an unusual case of a coronary artery fistula in a middle-aged woman who presented with symptoms of heart failure and abnormal auscultation. Echocardiography and conventional and computed tomography angiography showed that the coronary fistula originated from the left circumflex coronary artery and drained majorly into the right ventricle. Given the complex anatomy of the fistula, we managed it surgically rather than percutaneously. There were no complications early after surgery and at 1 year's follow-up.

Keywords: Computed tomography angiography; Fistula; Heart Defects* Congenital.

Figure 1

A) Transthoracic echocardiography (short-axis view at the AV level) shows an aneurysmal dilation in the left main coronary artery (arrow). B) Color Doppler interrogation (short-axis view at the AV level) shows an abnormal continuous flow (arrow) that starts from the dilated left main coronary artery and runs between the aorta and the pulmonary artery toward the posterior aspect of the LA. C) Pulsed Doppler study shows a continuous low-velocity flow, predominantly in diastole, which is consistent with a coronary artery fistula. D and E) Two-dimensional and color Doppler transesophageal echocardiography shows a severely dilated and tortuous left circumflex artery passing through the left atrioventricular groove toward the posterior aspect of the heart. F) An angulated view of transesophageal echocardiography (0° at the mid-esophageal level) shows the fistulous communication between the left circumflex artery and the RV inflow (arrow).

Figure 2

Right anterior oblique view with the caudal angulation view of diagnostic coronary catheterization shows a severely dilated LM, which bifurcates to a small LAD and an aneurysmal LCX. The asterisk shown is the site of the fistulous communication between the LCX and the right ventricle.

Figure 3

Coronary computed tomography angiography of the coronary arteries using maximum intensity projection (MIP) images (A and B) and volume-rendering technique (VRT) images (C and D). The origin and the termination site of the coronary fistula are clearly depicted in the MIP images. The surface anatomy, course, and shape of the giant tortuous coronary fistula, as well as its anatomic relationships with the RCA and the LAD, are readily appreciated in the VRT images, showing the anterior (C) and posterior (D) aspects of the heart.

Figure 4

Surgical view of the large aneurysmal circumflex artery (arrow)

Figure 5

Reconstructed computed tomography angiography (volume-rendering technique images) after the surgical repair of the coronary fistula and coronary artery bypass