Multisource Coronary Artery Fistula Draining Into the Coronary Sinus: Multimodality Imaging and Surgical Repair

Coronary artery fistula (CAF) is a rare congenital coronary anomaly. Multisource CAF draining into the coronary sinus is exceptionally uncommon and anatomically complex.

A woman presented with progressive exertional dyspnea and right-sided heart failure. Multimodality imaging, including transthoracic echocardiography, coronary computed tomography angiography, and invasive coronary angiography, demonstrated multisource CAFs arising from the right coronary artery and left circumflex artery draining into the coronary sinus with diffuse aneurysmal coronary dilatation. The patient underwent surgical ligation of the dominant right CAF with concomitant tricuspid annuloplasty. Postoperative imaging demonstrated successful closure of the dominant right CAF with thrombus formation within the ligated fistulous tract, whereas the smaller left circumflex artery fistula persisted, and serial follow-up demonstrated clinical improvement.

Multimodality imaging is essential for diagnosis, treatment planning, and postoperative surveillance of complex CAF. Surgical repair remains an effective treatment strategy for anatomically complex fistulas associated with significant hemodynamic consequences.