• coronary artery fistula
• Thebesian veins
• left ventricle

A previously healthy 55-year-old patient presented with progressive exertional chest pain. Physical examination showed no abnormalities except for a diastolic cardiac murmur. The ECG showed left ventricular hypertrophy. The laboratory findings and the chest x ray were normal.

An exercise treadmill test was positive. The echocardiogram showed multiple diastolic jets draining into the left ventricle. A coronary artery angiogram disclosed strongly dilated left and right coronary arteries with multiple microfistulae draining into the left ventricle (panels A and B). In our patient besides the diagnosis of microfistulae, a diagnosis of persistent venae cordis minimae (Thebesian veins) was also considered. However, because there were direct connections between the coronary arteries and visible small vessels draining into the left ventricle and because both coronary arteries showed tortuosity and were strongly dilated (flow-mediated dilatation), we believed that this was a case of multiple fistulae rather than persistent Thebesian veins.

Coronary artery fistulae have an incidence of 0.2 in patients undergoing diagnostic cardiac catheterisation. The normal sites of origin are the right coronary artery (5560), the left coronary artery (35), and both coronary arteries (5). The most common sites of termination are the right ventricle (40) and right atrium (23). Sporadically, coronary artery fistulae drain into the left ventricle. The definitive treatment for coronary artery fistulae is surgery or transcatheter embolisation, but given the anatomy, our patient is currently being evaluated for heart transplantation.