Coronary artery fistula associated with slow coronary flow: a rare cause of myocardial ischemia/Koroner arter fistulu ile koroner yavas akim birlikteligi: Miyokard iskemisinin nadir bir nedeni.

Coronary artery fistulas (CAF) and slow coronary flow syndrome (SCF) are rarely detected finding during coronary angiography. The coincidence of CAF with SCF is extremely rare and sometimes might cause myocardial ischemia.

We present a case of coronary-pulmonary artery fistula combined with SCF causing myocardial ischemia. A 55-year-old man presented with dyspnea on exertion of 6-months duration. Electrocardiogram showed diffuse T-wave inversion. Ischemia was revealed by radionuclide imaging. Coronary angiogram showed absence of significant narrowing; however, there was SCF on the left anterior descending coronary artery with TIMI frame count of 45 (Fig 1). In addition, a fistula between right coronary artery and pulmonary artery was observed (Fig. 2). Because the patient was symptomatic and myocardial ischemia was detected, we planned percutaneous closure of fistula; however, the patient refused this procedure and was treated medically. Coronary artery fistulas consist of a communication between a coronary artery and a cardiac chamber or major vessel. Therapeutic strategies of CAF are based on symptoms and shunt size. The SCF is characterized by delayed opacification of epicardial coronary arteries in the absence of stenotic lesion. It is an important clinical entity because it may be the cause of angina at rest or during exercise and acute myocardial infarction. The association of coronary artery fistulas and slow coronary flow should be kept in mind in management of patients with these types of coronary anomalies.

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Gurkan Acar, Ahmet Akcay, Alper Bugra Nacar, Cemal Tuncer Department of Cardiology, Medical Faculty, Sutcu Imam University Kahramanmaras, Turkey

Address for Correspondence/Yazisma Adresi: Dr. Gurkan Acar Sutcu imam University Medical Faculty Cardiology Department, Kahramanmaras, Turkey E-mail: [e-mail]