Description

A 77-year-old male patient with a history of bioprosthetic aortic valve replacement and a recently diagnosed urothelial carcinoma was referred to our cardiology outpatient clinic due to dyspnoea on mild exertion. A transthoracic echocardiogram revealed a moderate dilation of the left cardiac chambers, mild dilation of the right atria and pulmonary artery (with a normal-sized right ventricle), moderate pulmonary hypertension and severe left ventricle systolic dysfunction with low cardiac output (3.6 L/min). These findings had not been reported at the time of the cardiac surgery. The patient’s clinical status progressively worsened with respiratory failure requiring supplementary high flow oxygen. A coronary angiography was performed, excluding coronary artery disease and revealing a large coronary fistula arising from the left anterior descending artery and draining into the pulmonary artery (figure 1). The fistula was producing a coronary steal phenomenon, with significant myocardial ischaemia and systolic dysfunction, leading to heart failure. A cardiac CT confirmed that the fistula was arising from the left anterior descending artery and draining into the pulmonary artery through three different drainage branches. In its path, the fistula communicated with a vascular network. A fistula originating from the circumflex artery and ending in the superior vena cava was also identified (figure 2). Owing to an expected high surgical risk, a percutaneous closure of the larger fistula was scheduled, but the patient went into cardiopulmonary arrest refractory to resuscitation manoeuvres, induced by ischaemia and hypoxia, and died before any invasive treatment could be carried out.

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Figure 1

Coronary angiography showing the right anterior oblique view revealing a fistula arising from the left anterior descending artery and another one arising from the circumflex artery. LAD, left anterior descending; Cx, circumflex.

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Figure 2

Cardiac CT images in multiplanar reconstruction (A–C, E and F) and volume rendering (D) showing the fistulae, their origin, drainage and the vascular network. (A) Coronary fistula (white arrow) arising from the LAD artery (white triangle). (B) Coronary fistula vascular network (white arrow) next to the LAD artery (white triangle). (C) A fistula emerging from the vascular network with a posterior direction. (D) LAD artery coronary fistulae draining into the pulmonary artery (white arrows). (E) Coronary fistula (white arrow) arising from the Cx artery (white triangle). (F) Cx artery coronary fistula (white arrow) draining into the SVC. Ao, aorta; Cx, circumflex; LA, left atria; LAD, left anterior descending; SVC, superior vena cava.