Clinical picture

Angina caused by a giant coronary artery fistula A 49-year-old woman presented with 3 weeks of exertional chest pain. A trans-esophageal echocar-diogram with color Doppler was suggestive of a large coronary artery fistula 3.1 2.4 cm in size, originating from the left main coronary artery and emptying into the superior vena cava–right atrial junction. Coronary angiography demonstrated a dilated left main coronary artery with a giant fistu-lous channel draining into the high right atrium with otherwise normal coronary artery anatomy. Coronary steal was postulated as the etiology of the patient’s symptoms. She underwent surgical li-gation and resection of the coronary fistula with an uneventful postoperative course. Coronary artery fistulae are defined as vascular connections from a coronary artery, bypassing the myocardial capillary bed, to a cardiac chamber or major central blood vessel.1 It is a rare condition occurring in 0.2 % of the general population.2 Coronary artery fistulae are associated with compli-cations such as pulmonary hypertension, heart fail-ure, endocarditis, spontaneous rupture, thrombosis and myocardial ischemia secondary to a steal phe-nomenon.3 In patients with significant shunting, treatment strategies include percutaneous coiling, balloon embolization or surgical ligation.4 Supplementary material Supplementary material is available at QJME