Coronary-Cameral Fistula appeared after coronary artery intervention

A 63-year-old male with old myocardial infarction was referred to cardiology department with cardiac arrest. Electrocardiogram revealed Q wave in the precordial leads demonstrating ischemia of anterior left ventricular wall. Mild pulmonary edema was documented on chest X-ray. Transthoracic echocardiography showed severely reduced left ventricular function (EF: 28%) with enlarged left atrium and ventricle. Coronary angiography was performed showing a total occlusion of the proximal portion of the left anterior descending artery (LAD) (Figure 1) with chronic total occlusion in the proximal portion of right coronary artery. Xience stent 2.75 × 23 mm (Abbott) was implanted in the proximal LAD lesion. Coronary angiography after percutaneous coronary intervention (PCI) revealed no definite coronary fistula (Figure 2). Two weeks later, follow-up coronary angiography demonstrated multiple coronary-left ventricular fistulas (Figure 3) which were absent in the previous angiography.

Figure 1. Left coronary angiography demonstrating a total occlusion of proximal LAD.

LAD: left anterior descending artery.

Figure 2. Coronary angiography performed after coronary stent insertion.

Figure 3. Follow-up coronary angiography showing coronary-cameral fistula in the mid to distal portion of LAD.

LAD: left anterior descending artery.

Echocardiography after PCI showed small color flow signals from LAD territory of LV wall into LV chamber during a diastole in apical 3 chamber view (Figure 4A). Pulsed-wave Doppler image showed diastolic flow signal (Figure 4B). The patient was discharged from the hospital after the recovery from acute condition. The coronary fistula is a rare anomaly with an estimated incidence of approximately 0.002% in overall population.[1] There are many different imaging modalities including coronary angiography, which is the modality of the choice for evaluation of coronary artery fistula. Coronary artery fistula can be isolated (80%) or associated with congenital heart disease (20%).[2] It can be originating from any of coronary arteries, and drain into the cardiac chambers (right ventricle 14%–40%, right atrium 19%–26%, left atrium 5%–6%, and LV 2%–19%), great vessels (pulmonary artery 15%–43%, and superior vena cava 1%), and coronary sinus (7%).[3] Transthoracic echocardiography or transesophageal echocardiography may be utilized in detection of coronary artery fistula; however, it is challenging to elucidate the specific fistula anatomy.[3]

Figure 4. Transthoracic echocardiography showing an abnormal color flow from the fistula into the left ventricle detected in color Doppler image (A), Pulsed-wave Doppler of diastolic flow of fistula (B) in apical 4 chamber view.