Congenital coronary artery fistulas as a cause of angina pectoris

    Authors

    Abstract

    **Introduction**: Congenital coronary artery fistulas (CAFs) are coronary artery anomaly characterized by a direct connection between one or more coronary arteries and any of the 4 chambers or any of the great vessels. The incidence is approximately 0.08-0.3% of patients undergoing coronary angiography. (1) Coronary angiography is the gold standard for detecting the presence of coronary artery fistulas and estimation of their hemodynamic significance. CAFs that drain into the LV may cause myocardial ischemia due to coronary steal syndrome but rarely lead to hemodynamic impairment, due to high pressure in the LV. (2) Ageing increases the risk of their dilatation, thereby increasing the risk of complications. **Case report**: 72-year-old female with a history of arterial hypertension, dyslipidemia, and chronic obstructive pulmonary disease was hospitalized for anginal symptoms. She reported anginal symptoms during minimal physical activity and relieved by nitroglycerine. Echocardiography showed preserved systolic function with a discrete hypocontractility of the apical segment of the anterolateral and anterior wall. Coronary angiography showed coronary arteries without angiographically significant stenosis. However, intensive opacification of myocardial walls after contrast injection and contrast drainage into the ventricles through extensive multiple microfistulas were observed. Due to multiple and small-sized CAFs our patient was not suitable for interventional or surgical closure. The antianginal therapy was upgraded with trimetazidine (2x35 mg) and ranolazine (2x500 mg) with favorable response. **Conclusion**: Although a rare cause of angina pectoris, the coronary steal syndrome caused by the coronary arterial-ventricular fistulas should be considered during diagnostic work-up. Besides myocardial ischemia, CAFs may cause arrhythmias, heart failure, and infective endocarditis.

    Keywords

    angina pectoris, coronary artery fistula, coronary steal syndrome, coronary angiography

    DOI

    https://doi.org/10.15836/ccar2021.42

    Literature

    1. Kim CY, Choi JY, Kim KS. A coronary artery fistula having connection between 2 coronary arteries and the left ventricle: A case report. Medicine (Baltimore). 2017 November;96(45):e8546. https://doi.org/10.1097/MD.0000000000008546
    2. Kurt IH. Myocardial infarction caused by a fistula between the left anterior descending coronary artery and the left ventricle. Tex Heart Inst J. 2009;36(2):177–9. https://pubmed.ncbi.nlm.nih.gov/19436820/
    Cardiologia Croatica
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    Congenital coronary artery fistulas as a cause of angina pectoris

    Extended Abstract
    Issue1-2
    Published
    Pages42
    PDF via DOIhttps://doi.org/10.15836/ccar2021.42
    angina pectoris
    coronary artery fistula
    coronary steal syndrome
    coronary angiography

    Authors

    Petra Mjehović*ORCIDUniversity of Zagreb School of Medicine, Zagreb, Croatia
    Ana Reschner PlanincORCIDUniversity of Zagreb School of Medicine, Zagreb, Croatia
    Dubravka ŠipušORCIDUniversity of Zagreb School of Medicine, Zagreb, Croatia
    Maja ČikešORCIDUniversity of Zagreb School of Medicine, Zagreb, Croatia
    Hrvoje JurinORCIDUniversity of Zagreb School of Medicine, Zagreb, Croatia
    Joško BulumORCIDUniversity of Zagreb School of Medicine, Zagreb, Croatia
    Davor MiličićORCIDUniversity of Zagreb School of Medicine, Zagreb, Croatia
    Boško SkorićORCIDUniversity of Zagreb School of Medicine, Zagreb, Croatia

    *Correspondence email: petra.mjehovic@gmail.com

    Abstract

    **Introduction**: Congenital coronary artery fistulas (CAFs) are coronary artery anomaly characterized by a direct connection between one or more coronary arteries and any of the 4 chambers or any of the great vessels. The incidence is approximately 0.08-0.3% of patients undergoing coronary angiography. (1) Coronary angiography is the gold standard for detecting the presence of coronary artery fistulas and estimation of their hemodynamic significance. CAFs that drain into the LV may cause myocardial ischemia due to coronary steal syndrome but rarely lead to hemodynamic impairment, due to high pressure in the LV. (2) Ageing increases the risk of their dilatation, thereby increasing the risk of complications. **Case report**: 72-year-old female with a history of arterial hypertension, dyslipidemia, and chronic obstructive pulmonary disease was hospitalized for anginal symptoms. She reported anginal symptoms during minimal physical activity and relieved by nitroglycerine. Echocardiography showed preserved systolic function with a discrete hypocontractility of the apical segment of the anterolateral and anterior wall. Coronary angiography showed coronary arteries without angiographically significant stenosis. However, intensive opacification of myocardial walls after contrast injection and contrast drainage into the ventricles through extensive multiple microfistulas were observed. Due to multiple and small-sized CAFs our patient was not suitable for interventional or surgical closure. The antianginal therapy was upgraded with trimetazidine (2x35 mg) and ranolazine (2x500 mg) with favorable response. **Conclusion**: Although a rare cause of angina pectoris, the coronary steal syndrome caused by the coronary arterial-ventricular fistulas should be considered during diagnostic work-up. Besides myocardial ischemia, CAFs may cause arrhythmias, heart failure, and infective endocarditis.

    Literature

    1. 1.
      Kim CY, Choi JY, Kim KS. A coronary artery fistula having connection between 2 coronary arteries and the left ventricle: A case report. Medicine (Baltimore). 2017 November;96(45):e8546.DOI
    2. 2.
      Kurt IH. Myocardial infarction caused by a fistula between the left anterior descending coronary artery and the left ventricle. Tex Heart Inst J. 2009;36(2):177–9.PubMed