Introduction:
Fistula is defined as an inappropriate connection between two body parts, such as an organ or blood vessel and another structure. More specifically, a coronary artery fistula (CAF) is an abnormal connection between a coronary artery and a major vessel or cardiac chamber.
CAFs are extremely rare, can be asymptomatic, and are often detected incidentally; thus, the true incidence remains elusive [1]. CAFs can either be congenital or acquired.
Congenital CAFs are theorized to be secondary to incomplete embryonic development, in which the sinusoids that normally communicate the great vessels and chambers of the heart with the coronary arteries are incompletely closed. Acquired CAFs can occur as a result of atherosclerosis, procedure-induced trauma, or collagen vascular disease [2].
Previous literature has demonstrated that CAFs are present in only 0.05−0.25% of patients who undergo coronary angiography and in 0.9% of patients who undergo CTA [3].
Fistulas arising from the LAD constitute only 30% of CAFs, and those draining into the left side of the heart constitute a mere 10%, which was the case illustrated herein [4].
The American College of Cardiology recommends closure of all large fistulas regardless of symptoms due to the vast potential for and severity of complications, including ’theft’ from the adjacent myocardium, thrombosis and embolism, cardiac failure, atrial fibrillation, rupture, endocarditis/endarteritis, arrhythmias, ST-elevation myocardial infarction/non-ST elevation myocardial infarction, and even sudden cardiac death [5].
In this present case study, we describe a 41-year-old male with no significant past medical, surgical, or family history who presented with atypical chest pain.
The patient had a positive nuclear stress test and subsequently underwent installation of a left heart catheter, which revealed a large fistula between the LAD and the LV circumflex artery; however, subsequent CTA failed to demonstrate any evidence of a fistula being present.
We discuss the current imaging modalities and their respective advantages and limitations, in addition to providing an overview of disease management.