Coronary to pulmonary artery fistula associated with significant coronary atherosclerosis / Ciddi koroner aterosklerozun eslik ettigi koroner arter fistulu olgusu.

A 47-year-old man with history of smoking was admitted to our institution having exercise dyspnea and substernal chest pain for 3 months. He had no history of cardiac disease or trauma and his physical examination was normal. The 12-lead electrocardiogram revealed T wave inversion in leads V4-V6. The exercise treadmill stress test showed ST depression of 1.5 mm in leads V1-6. Coronary angiogram demonstrated a coronary artery fistula (CAF) originating from the proximal left anterior descending coronary artery superior to a critical atheromatous stenosis (Fig. 1), draining into the pulmonary artery (Fig. 2. Video 1. See corresponding video/movie images at www.anakarder.com). The patient was planned to undergo coronary surgery.

Among coronary vessel anomalies CAF is the rare entity(1). Although it is suggested that coronary arterial atherosclerosis affects patients with CAF in the same way as in normal humans (2); the combination of fistula and significant obstruction of the same coronary artery is by far a less frequent phenomenon (2-3). Myocardial ischemia resulting from fistula steal phenomenon cannot be clinically distinguished from that of coronary atherosclerosis, if these conditions coexist in the same patient. Although noninvasive imaging may facilitate the diagnosis and identification of the origin and insertion of CAF, coronary angiography is necessary to show the presence of concomitant atherosclerosis (4).

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References

(1.) Wandwi WB, Mitsui N, Sueda T, Orihashi K, Sueshiro M, Azuma K, et al. Coronary artery fistula to bronchial artery on contralateral side of coronary atherosclerosis and myocardial insufficiency. A case report. Angiology 1996; 47: 211-3.

(2.) Rangel A, Chavez E, Badui E, Diaz R, Solorio S, Verdin R, et al. Case report of association of congenital coronary fistulae with coronary atherosclerosis. Rev Invest Clin 1995; 47: 481-6.

(3.) Castedo E, Oteo JF, Burgos R, Ugarte M, Cristobal C, Tebar E, et al. Coronary artery fistula as a bypass of a left anterior descending coronary artery stenosis. Ann Thorac Surg 1997; 64: 1813-4.

(4.) Gowda RM, Vasavada BC, Khan IA. Coronary artery fistulas: clinical and therapeutic considerations. Int J Cardiol 2006; 107: 7-10.

Address for Correspondence/Yazisma Adresi: Nesligul Yildirim Zonguldak Karaelmas University Faculty of Medicine Department of Cardiology 67600, Kozlu, Zonguldak, Turkey Phone: [phone] E-mail: [e-mail]

Nesligul Yildirim, Sait M. Dogan, Metin Gursurer, Mustafa Aydin

Department of Cardiology, Faculty of Medicine,

Zonguldak Karaelmas University, Zonguldak, Turkey