Anomalous left anterior descending artery to coronary sinus fistula with associated localized ischemia: A clinical dilemma

PATIENT Female, 57 FINAL DIAGNOSIS: Coronary sinus - venous fistula Symptoms: Dispnoea Medication: - Clinical Procedure: - Specialty: Cardiology. OBJECTIVE Rare disease. BACKGROUND Coronary arterial fistula, or arteriovenous malformation (AVM), is a connection between the coronary tree and a cardiac chamber or great vessel, having bypassed the myocardial capillary bed. Known complications from coronary artery fistulas may include "steal" from the adjacent myocardium, resulting in myocardial ischemia. CASE REPORT We report the case of a 57-year-old Hispanic woman with abnormal preoperative electrocardiogram (ECG) and symptoms of dyspnea on exertion, who underwent a stress echocardiography demonstrating inferior distribution hypokinesis at peak exercise. Coronary computed tomography angiography (CCTA) demonstrated a venous fistula connecting the coronary sinus (CS) with the distal portion of the left anterior descending artery (LAD), occupying the territory of a left posterior descending artery (L-PDA) and corresponding in distribution with the patient's stress-induced wall motion abnormalities. CONCLUSIONS Anomalous left anterior descending artery to coronary sinus fistula with associated ischemia is a rare clinical dilemma with limited experience of success with either surgical or medical options.