Multimodality imaging of huge coronary cameral fistula

A 23-year-old man was hospitalized with the complaint of exertion dyspnea. Physical examination revealed a third degree diastolic murmur best heard at the left parasternal area. Electrocardiogram showed normal sinus rhythm. Transthoracic echocardiography revealed aneurysmatic dilatation of the left main coronary artery (CA) in addition to the large coronary cameral fistula between the left CA and left ventricle. The fistula travels in the interventricular septum and drains into the left ventricular cavity (Fig.1a, b, Video 1, 2) Coronary angiography and coronary computed tomography confirmed the huge fistula between the left CA and left ventricle (Fig. 1c–f, Video 3–5). The maximum diameter of fistula was 18 mm. CA fistulas are reported in 0.1%–0.2% of all patients undergoing selective coronary angiography. The major sites of origin of fistulas are right coronary artery (55%), left coronary artery (35%), and both (10%). The major sites of terminations are right ventricle (40%), right atrium (26%), and pulmonary artery (17%), and the relatively less frequent sires are SVC and CS, with the least frequency in the left atrium and left ventricle (2%). Herein, we have reported a huge coronary cameral fistula that connects the left main CA to the left ventricle.