Coronary artery to pulmonary artery fistula: Catheter or scalpel? A case report

INTRODUCTION: Coronary artery fistula (CAF) is an abnormal connection between coronary artery and a major vessel or cardiac chamber with left to right shunt having an incidence of 0.002 % in recent literature. Fistulous communication of coronary artery with pulmonary artery (PA) is a rare subtype and comprises of about 17 % of all the CAF cases. CASE PRESENTATION: We report a case of a middle-aged gentleman, known case of asymptomatic CAF for the last 20 years. He presented to us with 6 months history of chest pain on exertion. On coronory angiogram he was diagnosed to have a preexisting CAF of proximal LAD to main PA and severe coronary artery disease in left anterior descending coronary artery (LAD). He was managed surgically and underwent ligation of the fistula along with coronary artery bypass grafting (CABG). CLINICAL DISCUSSION: Management of CAF is medical, percutaneous or open-heart surgery. Due to rarity of the disease no international guidelines exists and treatment is controversial. Complications of CAF include endocarditis, early atherosclerosis, rupture, hemopericardium, pulmonary hypertension and myocardial ischemia, hence early correction is warranted. Our case emphasizes on the natural course of this rare disease and how to change management plan accordingly in the better interest of patient. CONCLUSION: Our case presents the natural course and management of a rare congenital cardiac disease. Surgery was chosen as an appropriate option due to CAD involving proximal LAD and concomitant coronary artery to PA fistula.