Congenital coronary artery pulmonary artery fistula causing steal phenomenon: case report and review of the literature

Departments of Surgery,College of Medicine, King Saud University, Riyadh, Saudi ArabiaCongenital coronary artery fistulas terminating in revealed a continuous murmur in the second and cardiac chambers, pulmonary artery, or systemic third left parasternal spaces. The ECG was normal, veins are the most common hemodynamically apart from a leftward axis with inverted T-waves in significant coronary congenital anomaly found in up leads 1II and AVF. Serum, electrolytes, blood urea to 0.2% of the adult population.' It was first nitrogen, creatinine, triglycerides, and complete described by Krause in 1865.2 The first surgically blood count were normal. The chest x-ray was treated patient was reported by Bijork and Crafoord unremarkable. in 19473 at thoracotomy in a patient diagnosed as a Echocardiographic study was within normal case of patent ductus arteriosus. limits. Coronary angiography showed bilateral coronary artery fistulas arising from the left anterior Case Report descending (LAD) and intermediate branches of the left coronary artery, the dye opacifing the A 54-year-old man was admitted to the coronary pulmonary artery and poor filling of the LAD due to care unit in another hospital following an a.tack of stealing of coronary flow (Figure 1). Right coronary chest pain that was associated with sweaung and injection demonstrated a critical lesion in the dizziness. His electrocardiogram (ECG) showed proximal right coronary artery (RCA) and two raised ST segment in leads 1II and VF and depressed proximal branches arising from the RCA and ST segments I, aVL, V4 and V6' The enzymes were feeding the fistula (Figure 2), The Qp/Qs was normal on admission but showed an early rise after 8 estimated to be 1.2:1. In view of the subjective and h and then gradually declined by the end of 24 h. objective findings, surgery was offered. The patient responded well to antianginal therapy. A Through median sternotomy, the creation of a continuous murmur was noticed in the second and pericardial cradle revealed angiomatous plexus with third left parasternal spaces. The patient was a palpable thrill, overlying the outflow tract of the referred to King Khalid University Hospital for right ventricle arising from the LAD and further management. intermediate branches of the left coronary artery On admission, his heart rate was 65 beats/min leading to a vascular channel that ended in the and regular; the blood pressure was 140/100 mm pulmonary artery about 1 cm above the level of the Hg. The patient was afebrile, had no edema of the pulmonary valve. A branch from the RCA was lower limbs, and the jugular venous pressure was passing over the left anterolateral aspect of the not raised. The apex beat was in the left fifth pulmonary artery to join the vascular channel