Right coronary artery to right atrial fistula: a case report

    Authors

    Keywords

    coronary artery fistula, right coronary artery, right atrium

    DOI

    https://doi.org/10.15836/ccar2026.16

    Full Text

    **Introduction:** A coronary artery fistula (CAF) represents an abnormal connection between a coronary artery and a cardiac chamber or great vessel, either congenital or acquired. The incidence of CAF on coronary angiography (CAG) is 0.2–0.6%, most commonly originating from the right coronary artery (RCA, 50–60%), left anterior descending (LAD, 25–42%), or circumflex artery (ACx, 18%). Small CAFs are often asymptomatic, while larger fistulas may produce myocardial steal, ischemia, or heart failure. Chronic high-flow fistulas can cause aneurysmal dilatation or thrombosis, requiring percutaneous transcatheter closure (TCC) or surgical ligation. (1-4) **Case report:** 58-year-old man presented with non-ST-elevation myocardial infarction (NSTEMI). CAG revealed subocclusive stenosis of the proximal LAD, 60–70% stenosis of the distal ACx and obtuse marginal (OM) 1, and no significant RCA stenosis. Percutaneous coronary intervention (PCI) with two drug-eluting stents (DES) was performed in the LAD. Incidentally, CAFs from the proximal LAD and RCA to the pulmonary artery (PA) were suspected on angiography (**Figure 1****).** Multislice computed tomography coronary angiography (MSCT) demonstrated a significant RCA-to-right atrium (RA) fistula located between the aorta and PA, forming a small vascular conglomerate adjacent to the RA (**Figures 2** and **3**Figure 3). Cardiac magnetic resonance imaging (MRI) was recommended for cardiac pulmonary artery flow (CPAF) and Qp:Qs ratio to assess shunt volume. The need for percutaneous closure will be evaluated based on these findings. FIGURE 1. Coronary angiogram of the coronary artery fistula originating from the proximal left anterior descending artery. FIGURE 2. Multislice computed tomography coronarography image of the coronary artery fistula originating from the proximal right coronary artery, located between the aorta and the pulmonary artery. FIGURE 3. Multislice computed tomography coronarography imaging of the coronary artery fistula lying between the aorta and the pulmonary artery and continuing into a vascular conglomerate. **Conclusion:** Coronary artery fistulas, although rare, may have serious clinical implications. When detected by angiography, complementary imaging with CT or MRI helps define anatomy and quantify shunt flow. In significant cases, percutaneous TCC should be considered to prevent ischemia, heart failure, or aneurysmal complications.

    Literature

    1. Yalçınkaya Öner D, Yarlıoğlueş M, Ergün E, Murat SN. Diagnosis, management, and treatment of coronary artery fistulas: three case reports and literature review. Inter Cardio Pers. 2025;1(2):75–81. https://doi.org/10.4274/intercardiopers.2025.2025-2-11
    2. Jabri A, Shahrori Z, Nasser MF, Bullinger K, Alameh A, Haddadin F, et al. Right Coronary Artery to Right Atrial Fistula: Role of Multi-Modality Imaging and Percutaneous Closure. Cureus. 2022 July 10;14(7):e26716. https://doi.org/10.7759/cureus.26716
    3. Buccheri D, Chirco PR, Geraci S, Caramanno G, Cortese B. Coronary Artery Fistulae: Anatomy, Diagnosis and Management Strategies. Heart Lung Circ. 2018 August;27(8):940–51. https://doi.org/10.1016/j.hlc.2017.07.014
    4. Wong RC, Teo SG, Yip JW. Coronary Artery to Right Atrium Fistula Associated With First Degree Atrioventricular Block: A Rare Association. ASEAN Heart J. 2013;21(2):4. https://doi.org/10.7603/s40602-013-0004-7
    Cardiologia Croatica
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    Right coronary artery to right atrial fistula: a case report

    Extended Abstract
    Issue1-2
    Published
    Pages16-17
    PDF via DOIhttps://doi.org/10.15836/ccar2026.16
    coronary artery fistula
    right coronary artery
    right atrium

    Authors

    Zrinko Pešut*ORCIDGeneral Hospital “Dr. Josip Benčević”, Slavonski Brod, Croatia
    Ivan BitunjacORCIDGeneral Hospital “Dr. Josip Benčević”, Slavonski Brod, Croatia
    Domagoj MiškovićORCIDGeneral Hospital “Dr. Josip Benčević”, Slavonski Brod, Croatia
    Ivica DunđerORCIDGeneral Hospital “Dr. Josip Benčević”, Slavonski Brod, Croatia
    Nikola GotovacORCIDPožega General Hospital, Požega, Croatia
    Blaženka MiškićORCIDGeneral Hospital “Dr. Josip Benčević”, Slavonski Brod, Croatia
    Katica Cvitkušić LukendaORCIDGeneral Hospital “Dr. Josip Benčević”, Slavonski Brod, Croatia

    *Correspondence email: zrink0@yahoo.com

    Full Text

    Introduction: A coronary artery fistula (CAF) represents an abnormal connection between a coronary artery and a cardiac chamber or great vessel, either congenital or acquired. The incidence of CAF on coronary angiography (CAG) is 0.2–0.6%, most commonly originating from the right coronary artery (RCA, 50–60%), left anterior descending (LAD, 25–42%), or circumflex artery (ACx, 18%). Small CAFs are often asymptomatic, while larger fistulas may produce myocardial steal, ischemia, or heart failure. Chronic high-flow fistulas can cause aneurysmal dilatation or thrombosis, requiring percutaneous transcatheter closure (TCC) or surgical ligation. (1–4)

    Case report: 58-year-old man presented with non-ST-elevation myocardial infarction (NSTEMI). CAG revealed subocclusive stenosis of the proximal LAD, 60–70% stenosis of the distal ACx and obtuse marginal (OM) 1, and no significant RCA stenosis. Percutaneous coronary intervention (PCI) with two drug-eluting stents (DES) was performed in the LAD. Incidentally, CAFs from the proximal LAD and RCA to the pulmonary artery (PA) were suspected on angiography (Figure 1). Multislice computed tomography coronary angiography (MSCT) demonstrated a significant RCA-to-right atrium (RA) fistula located between the aorta and PA, forming a small vascular conglomerate adjacent to the RA (Figures 2 and 3Figure 3). Cardiac magnetic resonance imaging (MRI) was recommended for cardiac pulmonary artery flow (CPAF) and Qp:Qs ratio to assess shunt volume. The need for percutaneous closure will be evaluated based on these findings.

    FIGURE 1. Coronary angiogram of the coronary artery fistula originating from the proximal left anterior descending artery.

    FIGURE 2. Multislice computed tomography coronarography image of the coronary artery fistula originating from the proximal right coronary artery, located between the aorta and the pulmonary artery.

    FIGURE 3. Multislice computed tomography coronarography imaging of the coronary artery fistula lying between the aorta and the pulmonary artery and continuing into a vascular conglomerate.

    Conclusion: Coronary artery fistulas, although rare, may have serious clinical implications. When detected by angiography, complementary imaging with CT or MRI helps define anatomy and quantify shunt flow. In significant cases, percutaneous TCC should be considered to prevent ischemia, heart failure, or aneurysmal complications.

    Literature

    1. 1.
      Yalçınkaya Öner D, Yarlıoğlueş M, Ergün E, Murat SN. Diagnosis, management, and treatment of coronary artery fistulas: three case reports and literature review. Inter Cardio Pers. 2025;1(2):75–81.DOI
    2. 2.
      Jabri A, Shahrori Z, Nasser MF, Bullinger K, Alameh A, Haddadin F, et al. Right Coronary Artery to Right Atrial Fistula: Role of Multi-Modality Imaging and Percutaneous Closure. Cureus. 2022 July 10;14(7):e26716.DOI
    3. 3.
      Buccheri D, Chirco PR, Geraci S, Caramanno G, Cortese B. Coronary Artery Fistulae: Anatomy, Diagnosis and Management Strategies. Heart Lung Circ. 2018 August;27(8):940–51.DOI
    4. 4.
      Wong RC, Teo SG, Yip JW. Coronary Artery to Right Atrium Fistula Associated With First Degree Atrioventricular Block: A Rare Association. ASEAN Heart J. 2013;21(2):4.DOI