Stolen from the coronaries: Left-to-Left shunts presenting as chest pain syndrome!

Area of Science:

• Cardiology
• Vascular Medicine

Background:

• Coronary artery fistulas are uncommon congenital or acquired abnormalities.
• Chest pain is a common symptom with diverse etiologies, including atherosclerotic and non-atherosclerotic causes.

Observation:

• A 61-year-old woman presented with chest pain syndrome.
• Standard cardiac catheterization excluded atherosclerotic coronary artery disease.
• A significant fistula between the left coronary artery and the left atrial appendage was identified.

Findings:

• The fistula caused a left-to-left shunt, leading to a 'coronary steal syndrome'.
• This steal phenomenon diverted blood flow away from the myocardium, causing ischemic symptoms.
• The fistula was identified as the cause of the patient's chest pain.

Implications:

• Coronary artery fistulas should be included in the differential diagnosis for patients presenting with unexplained chest pain.
• Understanding the pathophysiology of coronary steal syndrome is crucial for diagnosis and management.
• Interventional and surgical treatment options exist for hemodynamically significant coronary artery fistulas.