An unusual case of dual coronary artery fistulas to main pulmonary artery.

Coronary artery fistula is an anomaly in which a coronary artery directly connects to a cardiac chamber or great vessel. Its incidence is around 0.1 to 1% in the adult population. Dual coronary artery fistulas are far less common and their incidence is estimated to be around 5% in patients with this anomaly. Closure of the fistulas is indicated in patients with myocardial ischemia, large left to right shunt, congestive heart failure or other complications. Herein, we report a 64 year-old man with dual coronary artery fistulas presenting with exertional chest pain. The fistulas were initially suspected on transesophageal echocardiogram because of abnormal flow with a mosaic pattern between the left anterior descending and main pulmonary arteries. Selective coronary angiogram confirmed the diagnosis and revealed fistulous connections from the proximal left anterior descending and ostial right coronary arteries to the main pulmonary artery. The patient became symptom-free after surgical closure of the fistulas.