Poster (C38) - #STPE3 - Keywords: coronary artery fistula cardiac steal syndrome

THINKING OUT OF THE BOX IN CARDIAC STEAL SYNDROME: LATE PRESENTATION OF A RARE CORONARY ARTERY FISTULOUS ANOMALY

Hasitha Diana Manohar, MD; Monarch Shah, MD; Rohan Shah; Keval V. Patel, MD
1 Saint Peter's University Hospital/Rutgers Robert Wood Johnson Program, New Brunswick, NJ, USA. 2 Montgomery High School, Montgomery, NJ, USA.

ABSTRACT:
Background: A coronary artery fistula (CAF) is an abnormal communication, mostly congenital, between the coronary artery and one of the four chambers of the heart or a great vessel. Most cases arise from the right coronary artery (50-60%) followed by the left anterior descending (LAD) artery (25-42%). Case: A 51-year-old African male with a past medical history significant for hyperlipidemia and diabetes mellitus type 2 presented to the clinic with a chief complaint of dizziness for 15 mins. He was ironing when he had a sudden onset of dizziness, profuse sweating, fatigue, and shortness of breath. He has had similar shorter episodes since then. Seven months earlier, he had complaints of chest pain, shortness of breath, and fatigue. On arrival, the first set of vitals were normal. A physical examination was unremarkable. An electrocardiogram (EKG) showed normal sinus rhythm with standard ST and T wave. An echocardiogram performed seven months preceding onset of dizziness showed an EF 65-70%, with ectatic coronary arteries. Also, a nonischemic stress test. CT angiogram during the same time visualized a congenital coronary artery to the left ventricle fistula. There was a left-to-right shunt. The right coronary artery was dilated from its origin and along its entire course up to approximately 8 mm. It courses in the right atrioventricular groove and extends inferiorly and posteriorly around the heart in the distribution of the posterior lateral branch. At the level of the inferior aspect of the left atrium, the dilated vessel tapers where it enters the posterior portion of the left ventricular myocardium. The vessel measures approximately 2 mm as it traverses the left ventricular myocardium and drains into the left ventricle. This finding of a rare coronary artery anomaly may account for the patient’s symptoms. Decision‐making: Our patient was referred to a cardiothoracic surgeon for a symptomatic coronary artery anomaly. The treatment options being surgery or catheter closure. Conclusion: The fistulous connection results in blood bypassing the myocardial capillary network and a coronary steal phenomenon that manifests as an acute coronary syndrome (ACS).