A 69-year-old woman presented with an 18-year history of chest pain on exertion. The pain lasted for 10 to 15 minutes and was relieved by rest. She had no risk factors for coronary artery disease, and other co-morbidities. Her blood pressure was 140/80 mmHg and pulse rate was 64 beats per minute. On auscultation of the chest, continuous murmur was heard in the left middle sternal border.
The electrocardiogram showed normal sinus rhythm. Two-dimensional transthoracic echocardiography revealed a diastolic turbulent flow entering the pulmonary trunk, suggestive of a coronary artery fistula. Left ventricular ejection fraction was estimated at 68% without regional wall motion abnormalities. Multislice computed tomographic angiography (Figure 1) and coronary angiography (CAG) (Figure 2) demonstrated a huge coronary artery fistula connecting the left anterior descending coronary artery (LAD) to the pulmonary trunk with some foci of aneurysms. Given that it was complicated with symptomatic chronic myocardial ischemia, closure of the large coronary fistula was indicated in our patient. She was referred to Cardiac Surgery and underwent ligation of the fistula tract. A follow-up CAG performed seven days after the surgery, which revealed complete closure of the fistula without any residual shunt or compromise to the coronary circulation (Figure 3).
After an uneventful recovery, the patient was discharged and has been symptom-free during a six-month follow-up.
Closure of coronary artery fistulae are generally indicated in patients with symptoms of heart failure and myocardial ischemia, and in asymptomatic patients with high-flow shunting. Surgical methods of closure are associated with low mortality and excellent long-term outcome. Despite the good results with surgery, catheter-based intervention such as employing coils, detachable balloons, graft stents, gelfoam, and umbrella-like closure devices is now widely available and is considered as safe and effective alternatives to surgery. In our patient, the giant symptomatic coronary artery fistula connecting the LAD and main pulmonary artery was successfully closed by surgical ligation with significant improvement of the patient’s symptoms.