Coronary-Cameral Fistula to Pulmonary Artery: An Innocent Bystander?

J INVASIVE CARDIOL 2021;33(1):E70. doi:10.25270/jic/20.00108

Key words: cardiac catheterization, coronary angiography, coronary artery disease, coronary artery fistula, coronary steal, coronary vessel anomalies

A 65-year-old man presented to our emergency department with inferior-wall myocardial infarction. Coronary angiogram revealed a completely occluded right coronary artery and significant disease in the left anterior descending (LAD) and left circumflex arteries. Left coronary artery angiogram also showed a dilated and tortuous channel arising from the LAD. A coronary-cameral fistula (CCF) was seen originating from this feeding channel and draining into another chamber (Figure 1; Video 1). The location of the receiving chamber was confirmed by positioning a Judkin’s right catheter in the pulmonary artery and repeating the angiogram in multiple views. The chamber was anterior to the ascending aorta in the lateral view and to the left in the anteroposterior view, confirming it to be the pulmonary artery. There was an insignificant step up on oximetry with a Qp/Qs ratio of 1.1, suggesting a hemodynamically insignificant shunt. Contrast-enhanced computed tomography of the coronary arteries confirmed the diagnosis of CCF and the patient was advised to undergo coronary artery bypass grafting with ligation of the CCF.

CCF is a rare congenital communication between a coronary artery and a cardiac chamber or a great vessel. Most patients are asymptomatic and these lesions are incidentally detected during coronary angiography, with the reported incidence being up to 0.2%. The most frequent draining sites are right ventricle, right atrium, and pulmonary arteries, with less frequent drainage to the left side of the heart. The majority of CCFs are hemodynamically inconsequential and do not require treatment. However, when large, these lesions can cause myocardial ischemia because of coronary steal or high-output heart failure, and should be treated. Treatment modalities include transcatheter closure with embolic agents (microcoil or gelfoam) and surgical ligation. The choice of therapy is governed by the size of the CCF, tortuosity of the feeder channel, size of the distal communication to prevent device embolization, and concomitant coronary artery disease.

From the Department of Cardiology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India.

Disclosure statement: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.

The authors report that patient consent was provided regarding use of the images herein.

Final version accepted March 11, 2020.

Address for correspondence: Professor H.S. Isser, Department of Cardiology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi-110029, India. Email: drhsisser@gmail.com