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A 43 year old Japanese man was referred for investigation of occasional chest pain. He was a heavy smoker and was diagnosed as having familial hypercholesterolaemia. No heart murmur was heard. Chest x ray, electrocardiography, and two dimensional echocardiography showed no abnormal findings. Coronary angiography showed normal left and right coronary arteries and a coronary artery fistula between the left anterior descending artery and main pulmonary artery (panel A). Right catheterisation showed normal intracardiac pressures, and there was no increase in oxygen saturation in the pulmonary artery. Other examinations revealed no ischaemia.
At 51 years old the patient was diagnosed as having hypertension. Then, at 53 years of age, he was re-investigated before undergoing surgery for a right common iliac arterial aneurysm. Interestingly, repeat coronary angiography showed spontaneous closure of the previous coronary artery fistula (panel B). The right coronary artery had peripheral stenosis but other sites were not stenotic.
Spontaneous closure of a coronary artery fistula is rare. It has been estimated to occur in 1% of all reported cases of coronary artery fistulae. Eleven cases have been previously reported; eight cases were under 15 years old and only three cases were adult. The mechanism of spontaneous closure is unclear. Previous reports suggested atherosclerosis, embolism, and vasospasm may be involved. Our patient had familial hypercholesterolaemia, hypertension, and smoked. Thus, spontaneous closure of the fistula may have been caused by an atheromatous plaque.