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A 56-year-old man with no known cardiac risk factors presented with dyspnea upon exertion. The vital signs were normal. Echocardiography showed normal left ventricular (LV) ejection fraction and no valvular disease, but moderate LV hypertrophy and LV diastolic dysfunction were noted. Rest and stress myocardial perfusion scintigraphy showed a reversible inferior-wall perfusion defect; therefore, an initial diagnosis of coronary artery disease was made. Coronary arteriography showed no atherosclerotic lesions in the 3 major coronary arteries; however, all 3 arteries communicated with the LV cavity through many small, diffuse fistulae (Figs. 1 and and2),2), resulting in complete LV contrast opacification. The coronary sinus appeared to be of normal size. The inferior-wall ischemia that was shown on nuclear stress imaging was attributed to coronary steal phenomenon. The patient was placed on medical therapy.
Coronary artery fistula is an abnormal direct connection between a coronary artery and either a cardiac chamber (coronary–cameral fistula) or a vein (coronary arteriovenous fistula). Coronary artery fistulae are observed at an incidence of 0.1%.1 Rarely, they may cause myocardial ischemia from coronary steal, heart failure, or spontaneous intrapericardial rupture. Sixty percent of these fistulae arise from the right coronary artery, and 90% terminate in the right side of the heart. Coronary–cameral fistulae from all 3 major coronary arteries into the LV is a rare observation.2,3
Coronary–cameral fistulae are often congenital, and they may be related to normally observed Thebesian veins that conduct postcapillary coronary artery blood flow into cardiac chambers. These are usually of no clinical significance and are not clinically apparent. Depending upon the size and location of the fistulae, epicardial and endocardial surgical ligation or percutaneous endoluminal procedures (embolization) may be performed in some cases. Intervention is difficult or impossible when the fistulae are diffuse. Therefore, despite the ischemia in our patient, intervention was not considered.4
Address for reprints: Selma Kenar Tiryakioglu, MD, Department of Cardiology, Bursa Acibadem Hospital, Sumer sok. No:1, 16110 Nilufer, Bursa, Turkey