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A40 year old normotensive, diabetic man presented to the emergency department in congestive heart failure. He had been diagnosed elsewhere with dilated cardiomyopathy. The ECG revealed T wave inversion in precordial leads, and echocardiography showed dilated left ventricle (LV) with global hypokinesia and severe LV dysfunction. 99mTc labelled RBC MUGA showed an enlarged LV with ejection fraction of 23%, and 99mTc-sestamibi resting myocardial perfusion study revealed reduced tracer concentration in the anterior wall and septum and viable myocardium in these areas. A subsequent coronary angiogram showed multiple coronary fistulas from the septal branches of the left anterior descending coronary artery (LAD) draining into the pulmonary artery (below left). A 3 × 19 mm Jostent coronary stent graft was deployed in the LAD to occlude the septal arteries feeding the fistulas. As the post deployment angiogram (below centre) showed residual fistulas from the septal branches distal to the stent, another 3 × 12 mm Jostent was deployed in the distal part of the first stent occluding the septals causing residual fistulas. The final angiogram showed good antegrade flow in the LAD with obliteration of fistulas (below right).
Coronary fistulas most commonly originate from the right coronary artery and the majority are asymptomatic. The related problems that occur usually are myocardial ischaemia and angina (the result of a “coronary steal”), congestive heart failure, bacterial endocarditis, cardiac arrhythmia or rupture of an aneurysmal fistula. Current treatment options include surgical ligation and coil embolisation. Recently covered stents have been successfully employed for the closure of coronary fistulas.