Acquired left coronary artery fistulae to pulmonary artery and superior vena cava.

To cite: Faustino A, Paiva LV, Mota P, et al. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/bcr-2013202267 DESCRIPTION A 77-year-old male patient with a history of bioprosthetic aortic valve replacement and a recently diagnosed urothelial carcinoma was referred to our cardiology outpatient clinic due to dyspnoea on mild exertion. A transthoracic echocardiogram revealed a moderate dilation of the left cardiac chambers, mild dilation of the right atria and pulmonary artery (with a normal-sized right ventricle), moderate pulmonary hypertension and severe left ventricle systolic dysfunction with low cardiac output (3.6 L/min). These findings had not been reported at the time of the cardiac surgery. The patient’s clinical status progressively worsened with respiratory failure requiring supplementary high flow oxygen. A coronary angiography was performed, excluding coronary artery disease and revealing a large coronary fistula arising from the left anterior descending artery and draining into the pulmonary artery (figure 1). The fistula was producing a coronary steal phenomenon, with significant myocardial ischaemia and systolic dysfunction, leading to heart failure. A cardiac CT confirmed that the fistula was arising from the left anterior descending artery and draining into the pulmonary artery through three different drainage branches. In its path, the fistula communicated with a vascular network. A fistula originating from the circumflex artery and ending in the superior vena cava was also identified (figure 2). Owing to an expected high surgical risk, a percutaneous closure of the larger fistula was scheduled, but the patient went into cardiopulmonary arrest refractory to resuscitation manoeuvres, induced by ischaemia and hypoxia, and died before any invasive treatment could be carried out.