Coronary Artery-Left Ventricular Fistula and Takotsubo Cardiomyopathy – An Association or an Incidental Finding? A Case Report

Abstract

Patient: Female, 68Final Diagnosis: Takotsubo cardiomyopathySymptoms: Chest pain • shortness of breathMedication: —Clinical Procedure: Percutaneous coronary artery angiographySpecialty: CardiologyObjective:Rare co-existance of disease or pathologyBackground:A coronary artery-left ventricular fistula is an anomalous communication between the coronary arteries and the cardiac chambers and is a rare congenital coronary anomaly that is often small and asymptomatic. Takotsubo cardiomyopathy, on the other hand, is a syndrome characterized by transient regional systolic dysfunction of the left ventricle, mimicking myocardial infarction, but in the absence of angiographic evidence of obstructive coronary artery disease or acute plaque rupture. We present the case of an elderly woman who presented with Takotsubo cardiomyopathy and who was incidentally discovered to have an associated coronary artery-left ventricular fistula.Case Report:We report the case of a 68-years-old woman with a family history of premature cardiac diseases who presented with ischemic chest pain and elevated troponin levels. Her EKG and troponins were suggestive of non-ST-elevation myocardial infarction (NSTEMI), for which she was initially treated medically and later underwent coronary angiography. Unexpectedly, the angiography revealed patent coronary arteries, and we discovered evidence of coronary artery to left ventricular fistula in the addition to angiographic evidence of Takotsubo cardiomyopathy. A working diagnosis of Takotsubo was made, for which she was treated medically with resulting improvement of her symptoms and later in the imaging findings.Conclusions:This described case illustrates a rare association between coronary artery fistulas and Takotsubo cardiomyopathy. It is unclear if this association has played a role in the pathogenesis or perhaps is just an incidental finding. More similar cases are needed to expand the clinical presentation of both conditions and add to the literature.

Coronary artery–left ventricular multiple microfistulas, a rare disease that is easily missed: case report and literature review

“…On one hand, the coronary artery steal phenomenon causes insufficient blood supply to the distal coronary artery, resulting in chest pain and even myocardial infarction. 11,12 On the other hand, continuous extra blood flow will increase the heart load, resulting in congestive heart failure and pulmonary hypertension, which will in turn lead to dyspnea, chest tightness, and other related symptoms. 2,5,13 The shunt flow through the fistula mainly depends on the size of the fistula and the pressure gradient between the coronary artery and the drainage site.…”

“…In addition, our patients' coronary angiography results suggest that during systole, the microvascular fistulas close under pressure and the abnormal blood flow stops, which also reduces the degree of "coronary steal" to some extent. This special hemodynamic change means that the degree of myocardial ischemia and cardiac load increase in most patients with CALVMMFs may not be obvious, 11,14 and these patients may therefore have no obvious clinical symptoms or will require a long time to develop obvious symptoms. In our case series, the cardiac function of all except one patient with left ventricular diastolic dysfunction was not markedly decreased, indicating that these patients may have a good prognosis.…”

An intramural left ventricular fistula caused by left ventriculography

“…[6] Symptoms may include ischemic myocardium, pulmonary hypertension, heart failure, angina, heart failure, myocardial infarction, thromboembolism of the fistula, endocarditis, and cardiomyopathy. [7] Almost all the cardiac fistulas including the left ventriclar and CS fistula require surgical closure. Percutaneous closure aided with three-dimensional computed tomography is a well described strategy in the catheterization lab with a low post operative mortality and morbidity.…”