Rare case of coronary to pulmonary vein fistula with coronary steal phenomenon

Abstract

Coronary artery fistulas are abnormal connections between coronary artery territories and cardiac chambers or major vessels, most of them are congenital. Patients with coronary artery fistula can be asymptomatic or present with different symptoms like angina. Cardiac computed tomography (CT) is one of the best modalities for diagnosis. We present an elderly patient that presented with angina symptoms, non invasive stress test was positive for ischemic heart disease, coronary angiogram could not reveal any obstructive lesions, but an abnormal branch of the left descending coronary artery (LAD), cardiac CT showed fistula that connect left anterior descending coronary artery to left superior pulmonary vein. Our case is extremely rare as most of the reported cases were fistulas between LAD and pulmonary artery, but in our case the fistula between LAD and left superior pulmonary vein. In addition, our patients' symptoms resolved with anti-ischemic medical treatment without any surgical intervention.

Left internal mammary artery to pulmonary artery fistula causing coronary steal syndrome: A review of literature on therapy, intervention, and management

“…This angiogenesis may then lead to new fistula tract formation between various vessels. Other theories include incomplete ligation of the intercostal branches of the LIMA . Some suggest that the increased use of electro‐cautery, as opposed to older techniques of side branch ligation, may be the cause of fistula tract formation .…”

“…The common theme between each of these management options is that cardiac clinicians chose the option available that offered them the best possibility to achieve lasting reduction in fistula flow, and thus a reduction in both ischemia and symptoms. In most cases, conservative medical management was considered first if symptoms were amenable to this option . In patients who needed repeat revascularization with CABG, open surgical revision of the fistula was undertaken concomitantly .…”

“…Other theories include incomplete ligation of the intercostal branches of the LIMA. 10,12 Some suggest that the increased use of electro-cautery, as opposed to older techniques of side branch ligation, may be the cause of fistula tract formation. 6 Based on previous cases, surgeons may be well-suited to avoid any simultaneous lung resection while harvesting LIMA grafts.…”

“…In most cases, conservative medical management was considered first if symptoms were amenable to this option. 12,15 In patients who needed repeat revascularization with CABG, open surgical revision of the fistula was undertaken concomitantly. 5 When patients were found to have native coronary vessels that were amenable to PCI, then PCI was done to native coronaries to even out pressure differences on either side of the patient's fistula.…”

Coronary artery fistula between the left anterior descending artery and pulmonary artery

“…6 Complications from CAF include steal mediated myocardial ischemia, thrombosis and embolism, high-output cardiac failure, atrial fibrillation, rupture, endocarditis/endarteritis, and arrhythmia. 7 Patients most commonly present with symptoms of dyspnea or angina pectoris and occasionally arrhythmias. In patients with high-flow CAFs, a continuous precordial murmur may be auscultated.…”