Postprandial angina: not always due to stenotic coronary artery disease.

Ghosh GC, et al. BMJ Case Rep 2017. doi:10.1136/bcr-2017-223030 Description A 68-year-old man presented with history of postprandial angina for 6 months. He was a diabetic and hypertensive for 10 years. He was also a reformed smoker with 20 pack-years history of smoking. He did not give any history of acute coronary syndrome or any cardiac catheterisation. Clinical examination was unremarkable. ECG and chest X-ray were normal. Echocardiography revealed normal left ventricular function with features of left ventricular hypertrophy. Coronary angiography revealed abnormal spillage of contrast in the left ventricular apical region with each diastole from obtuse marginal (OM) branch of left circumflex coronary artery (LCx) and distal part of left anterior descending coronary artery (LAD) suggestive of coronary–cameral fistula (CCMF) (figure 1, figure 2, online supplementary video 1). Coronary angiography did not show any signs of atherosclerotic coronary artery disease. Absence of dilated communicative fistulous tracts between the coronary arteries and the drainage chamber was suggestive of arteriosinusoidal type of CCMF (online supplementary videos 2 and 3). Patient was managed conservatively. CCMF is a communication between any of the coronary arteries and any of the cardiac chambers or major vessels like pulmonary artery and coronary sinus. CCMF is a very rare cardiac anomaly, commonly congenital in origin but can also develop as a complication of cardiac trauma during cardiac catheterisation. Most of the CCMF are incidentally detected during coronary angiography. Vavuranakis et al have reported an incidence of 0.1% in the unselected patients undergoing diagnostic coronary angiography. CCMF originates from the right coronary artery (55%), left coronary artery (35%) and both coronary arteries (5%) and commonly drains into the right ventricle (40%), right atrium (26%) and pulmonary arteries (17%). Drainage into the superior vena cava and coronary sinus is rare, and into the left atrium and left ventricle is hardly reported in the literature. Mostly CCMF are asymptomatic and the development of symptoms depends on the size of the fistula, site of origin and drainage of the communication tracts. Anginal symptoms are due to coronary steal phenomenon or diastolic overload of the drainage chamber. Other rare complications of Coronary-cameral fistula (CCMF) are thrombosis and embolism, cardiac failure, atrial fibrillation, rupture, endocarditis/endarteritis and arrhythmias. Based on the types of the communication, CCMF can be divided into (1) arterioluminal (direct communication with cardiac chambers) and (2) arteriosinusoidal (communication via sinusoidal network into a chamber without a direct communication) subtypes. This differentiation is helpful in determining the management plan. Symptomatic arterioluminal subtype can be successfully closed by surgery or device, whereas arteriosinusoidal subtype is less amenable to surgery and beta blockers can be tried as an alternative. Postprandial angina: not always due to stenotic coronary artery disease