Coronary-pulmonary artery fistula: value of 64-MDCT imaging.

A 57-year old previously healthy male presented following an episode of sudden-onset central chest tightness and syncope whilst driving. There was no prior history of such episodes. Baseline observations, physical examination, electrocardiograph and chest radiograph were all normal. Cardiac biomarkers were negative and transthoracic echocardiography revealed a structurally and functionally normal heart. The coronary arteries were assessed using 64-slice multi-detector computed tomography (64-MDCT). This unexpectedly revealed a large fistula (Figure 1, arrow) connecting the septal branch of the left anterior descending (LAD) coronary artery to the main pulmonary trunk (PA). An extensive reticulum of smaller feeder vessels (Figure 1, arrowhead) was also seen connecting the left coronary arterial system to the PA. Invasive coronary angiography was then performed through the femoral route that confirmed the presence of the fistula (Figure 2, arrow). The patient underwent surgery during which the 8mm fistula and the feeder vessels were disconnected and ligated. Repeat 64-MDCT (Figure 3) demonstrated complete resolution of the fistula. The common cardiac causes of chest pain include coronary artery disease, pericarditis, myocarditis and type A aortic dissection. There are, in addition, a variety of non-cardiac conditions causing chest pain including pulmonary embolism, type B aortic dissection, gastro-oesophageal disease, lung and musculoskeletal pathology. Syncope, similarly is associated with a wide range of diagnoses including arrhythmias, structural cardiovascular problems and cerebrovascular disease. Coronary–pulmonary fistulae are rare causes of chest pain and syncope.