A case of coronary-cameral fistulae involving all three major coronary arteries.

e describe a case of a 61-year-old female patient who underwent coronary angiography for the investigation of short-lasting chest pain episodes at rest. Her medical history consisted of dyslipidemia as the only risk factor for coronary artery disease. Clinical examination was unremark-able with no signs of heart failure or additional heart murmurs. The results of a standard 12-lead ECG were normal, but the treadmill test was suggestive of ischemia due to borderline ST depression in the inferior leads on high workload. Transthoracic echocardiography, besides a normal size and function left ventricle, revealed also some color flow throughout diastole from the lateral epicardial surface into the left ventricular cavity (Figure A and Movies I and II in the online-only Data Supplement). Coronary angiography showed normal epicardial coronary arteries. However, during selective angiography of all 3 major coronary arteries, there was extensive draining of the contrast agent to the left ventricular cavity through many small, diffuse fistulae, resulting in complete left ventricular contrast opacification (Figure B through D and Movies III through V in the online-only Data Supplement). There was no significant intracardiac shunt related to the fistulae. Continuous saturation monitoring during the procedure revealed normal oxygen saturation (98%–100%). The coronary sinus appeared to be of normal size. Thus, the diagnosis of coronary-cameral fistulae from all 3 coronary arteries was considered. Coronary fistula is an abnormal congenital or acquired connection between a coronary artery and either a cardiac chamber (coronary-cameral fistula) or a vein (coronary arteriovenous fistula). Coronary-cameral fistula (CCF) is a rare entity reported in ≈0.08% to 0.3% of unselected patients undergoing diagnostic coronary angiography. The right coronary artery is the usual origin of the communication, draining in the right-sided chambers of the heart in 90% of cases. The connection between the left coronary arteries and the left ventricle occurs in only 10% of CCF, whereas a CCF originating from all 3 major coronary arteries that terminates into the left ventricle is an extremely rare phenomenon. 3 Our case is unusual, not only because of the rareness of the particular type of CCF, but also because of the asymp-tomatic clinical course for many years despite the presence of multiple and significant left ventricular communications. Such sizable communications would be expected to cause symptoms of increased left ventricular end-diastolic pressure and myocardial ischemia as a result of arterio-arterial shunt and the myocardial blood flow–stealing effect distal to the site of the CCF …