Case report
Congenital coronary artery fistula in an intercoronary communication between the left main and the diagonal branch of the left anterior descending coronary artery: An interesting case report
Fístula congénita da artéria coronária na comunicação intercoronária entre o trono comum e um ramo diagonal da artéria coronária descendente anterior esquerda: um caso clínico interessante
Department of Cardiology, Duzce University, Duzce, Turkey
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It is defined as an open-ended circulation with bidirectional blood flow between two coronary arteries.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> It can be distinguished from collateral arteries by its angiographic features, and in itself does not usually reflect underlying coronary artery disease.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Intercoronary arterial connections are thought to be congenital in origin. Compared with collaterals, intercoronary arterial connections are larger in diameter (>1 mm), extramural, and straight. Furthermore, the structure of an intercoronary arterial connection is typical of an epicardial coronary artery, with a well-defined muscular layer.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Coronary artery fistulas are abnormal communications between a coronary artery and a cardiac chamber or major vessel.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> They may be congenital or acquired due to trauma or iatrogenic causes. Angiographic series reveal an incidence of coronary artery fistula in adults of 0.3–0.8%.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4–6</span></a> Most of these patients are asymptomatic, but heart failure, angina, myocardial infarction, coronary steal, endocarditis, and dyspnea have been reported.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">We report an interesting case of congenital coronary artery fistula in an intercoronary communication between the left main and the diagonal branch of the left anterior descending coronary artery presenting as an acute coronary syndrome.</p><p id="par0020" class="elsevierStylePara elsevierViewall">To the best of our knowledge, this is the first case in the literature involving a coronary artery fistula in an intercoronary communication.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0025" class="elsevierStylePara elsevierViewall">A 62-year-old man was admitted to our hospital with sudden development of general weakness, dizziness and a sensation of compression in his chest. He had a history of diabetes mellitus. At presentation his blood pressure was 80/40 mmHg and heart rate was 65 beats/min. The ECG revealed sinus rhythm and 1–2 mm ST elevation in the anterior leads (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>). The patient was taken to the catheterization laboratory for percutaneous coronary intervention. The left main and left circumflex coronary arteries were normal. Coronary angiography showed a communication between the left main and the diagonal branch of the left anterior descending and a fistula between the intercoronary connection and the left atrium (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>). The other coronary arteries were normal. Laboratory test results, including cardiac troponin I and creatine kinase–MB levels, were normal. The angina symptoms disappeared and the ST elevation resolved within four hours (<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>). To the best of our knowledge, this is the first case in the literature involving a congenital coronary artery fistula in an intercoronary communication.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0030" class="elsevierStylePara elsevierViewall">The hemodynamic consequences of coronary artery fistulas are variable depending on shunt size, site of the shunt and presence of other underlying heart disease.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Fifty percent of patients with large or multiple fistulas may develop complications, which may include bacterial endocarditis, thrombosis, aneurysm formation, dissection, rupture, premature atherosclerosis, pulmonary hypertension, myocardial ischemia, or infarction.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The functional significance of large intercoronary communications between normal coronary arteries is unclear but one may speculate that they have a potential role in protecting the myocardium should significant atherosclerosis develop in either of the patent arteries<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>; on the other hand, myocardial ischemia could result if an unidirectional intercoronary communication causes a coronary steal phenomenon that results in inadequate perfusion.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> The ischemic consequences of an intercoronary connection with unidirectional flow may be explained by its similarity to a fistula from a coronary artery to a low-pressure cardiac space.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">We believe that an intercoronary communication between the left main and the diagonal branch of the left anterior descending coronary artery and a congenital coronary artery fistula may be the cause of ischemia in this case.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Ethical disclosures</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Protection of human and animal subjects</span><p id="par0045" class="elsevierStylePara elsevierViewall">The authors declare that the procedures followed were in accordance with the regulations of the relevant clinical research ethics committee and with those of the Code of Ethics of the World Medical Association (Declaration of Helsinki).</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Confidentiality of data</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data and that all the patients included in the study received sufficient information and gave their written informed consent to participate in the study.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Right to privacy and informed consent</span><p id="par0055" class="elsevierStylePara elsevierViewall">The authors have obtained the written informed consent of the patients or subjects mentioned in the article. The corresponding author is in possession of this document.</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conflicts of interest</span><p id="par0060" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:2 [ "identificador" => "xres311351" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec294492" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres311352" "titulo" => "Resumo" ] 3 => array:2 [ "identificador" => "xpalclavsec294493" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:3 [ "identificador" => "sec0020" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0025" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0030" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0035" "titulo" => "Right to privacy and informed consent" ] ] ] 8 => array:2 [ "identificador" => "sec0040" "titulo" => "Conflicts of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2013-06-17" "fechaAceptado" => "2013-07-04" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec294492" "palabras" => array:3 [ 0 => "Acute coronary syndrome" 1 => "Coronary artery fistula" 2 => "Intercoronary communication" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec294493" "palabras" => array:3 [ 0 => "Síndrome coronária aguda" 1 => "Fístula da artéria coronária" 2 => "Comunicação intercoronária" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Intercoronary communication is a very rare coronary artery anomaly. It is defined as an open-ended circulation with bidirectional blood flow between two coronary arteries. Coronary artery fistulas are abnormal communications between a coronary artery and a cardiac chamber or major vessel. A 62-year-old man was admitted to our hospital with sudden development of general weakness, dizziness and a sensation of compression in his chest. At presentation his blood pressure was 80/40 mmHg and heart rate was 65 beats/min. The ECG revealed sinus rhythm and 1–2 mm ST elevation in the anterior leads. The patient was taken to the catheterization laboratory for percutaneous coronary intervention. The left main and left circumflex coronary arteries were normal. Coronary angiography showed a communication between the left main and the diagonal branch of the left anterior descending and a fistula between the intercoronary connection and the left atrium. The other coronary arteries were normal. Laboratory test results, including cardiac troponin I and creatine kinase–MB levels, were normal. The angina symptoms disappeared and the ST elevation resolved within four hours. We report an interesting case of congenital coronary artery fistula in an intercoronary communication between the left main and the diagonal branch of the left anterior descending coronary artery presenting as an acute coronary syndrome. To the best of our knowledge, this is the first case in the literature involving a coronary artery fistula in an intercoronary communication.</p>" ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A comunicação intercoronária é uma anomalia muito rara da artéria coronária. Define-se como circulação em aberto com um fluxo sanguíneo bidirecional entre as duas artérias coronárias. As fístulas das artérias coronárias são comunicações anormais entre a artéria coronária e uma câmara cardíaca ou um vaso principal. Um homem de 62 anos foi admitido no nosso hospital revelando fraqueza geral súbita, tonturas e sensação de compressão no peito. No momento apresentava pressão arterial de 80 mmHg/40 mmHg e frequência cardíaca de 65 batimentos/min. O eletrocardiograma (ECG) revelou ritmo sinusal e elevação do segmento ST de 1-2 mm nas derivações anteriores. O doente foi conduzido para o laboratório de hemodinâmica para intervenção coronária percutânea. O tronco comum e as artérias coronárias circunflexas esquerdas estavam normais. A angiografia coronária mostrou uma comunicação entre o tronco comum e o ramo diagonal da artéria descendente anterior e uma fístula entre a comunicação intercoronária e a aurícula esquerda. As outras artérias coronárias estavam normais. Os resultados dos testes laboratóriais, incluindo os níveis de troponina I cardíaca e de creatina-kinase MB estavam normais. Os sintomas de angina desapareceram e a elevação do segmento ST foi resolvida após 4 horas. Relatamos um caso interessante de uma fístula congénita da artéria coronária na comunicação intercoronária entre o tronco comum e o ramo diagonal da artéria coronária descendente anterior esquerda apresentadas como uma síndrome coronária aguda. De acordo com o nosso conhecimento relatamos o primeiro caso na literatura que envolve uma fístula da artéria coronária na comunicação intercoronária.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1115 "Ancho" => 3000 "Tamanyo" => 752137 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Electrocardiogram revealing 1–2 mm ST elevation in the anterior leads.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1305 "Ancho" => 1584 "Tamanyo" => 170583 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Contrast injection in the left coronary artery showing a large connection between the left main and the diagonal branch of the left anterior descending (black arrow) and a fistula between the intercoronary connection and the left atrium (white arrow). D: diagonal; LM: left main.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1029 "Ancho" => 3000 "Tamanyo" => 306667 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Electrocardiogram demonstrating normal sinus rhythm.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:11 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Coronary artery anomalies in 126,595 patients undergoing coronary arteriography" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "O. Yamanaka" 1 => "R.E. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 October | 39 | 35 | 74 |
| 2024 September | 72 | 27 | 99 |
| 2024 August | 63 | 43 | 106 |
| 2024 July | 51 | 34 | 85 |
| 2024 June | 55 | 38 | 93 |
| 2024 May | 41 | 29 | 70 |
| 2024 April | 51 | 37 | 88 |
| 2024 March | 36 | 19 | 55 |
| 2024 February | 46 | 28 | 74 |
| 2024 January | 37 | 25 | 62 |
| 2023 December | 29 | 23 | 52 |
| 2023 November | 43 | 35 | 78 |
| 2023 October | 28 | 19 | 47 |
| 2023 September | 21 | 19 | 40 |
| 2023 August | 35 | 21 | 56 |
| 2023 July | 24 | 11 | 35 |
| 2023 June | 21 | 13 | 34 |
| 2023 May | 60 | 24 | 84 |
| 2023 April | 49 | 12 | 61 |
| 2023 March | 52 | 24 | 76 |
| 2023 February | 52 | 16 | 68 |
| 2023 January | 15 | 7 | 22 |
| 2022 December | 36 | 19 | 55 |
| 2022 November | 49 | 16 | 65 |
| 2022 October | 28 | 19 | 47 |
| 2022 September | 26 | 18 | 44 |
| 2022 August | 23 | 29 | 52 |
| 2022 July | 41 | 31 | 72 |
| 2022 June | 26 | 20 | 46 |
| 2022 May | 23 | 33 | 56 |
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| 2021 September | 24 | 20 | 44 |
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| 2021 July | 29 | 25 | 54 |
| 2021 June | 26 | 13 | 39 |
| 2021 May | 33 | 24 | 57 |
| 2021 April | 32 | 24 | 56 |
| 2021 March | 80 | 12 | 92 |
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| 2021 January | 41 | 13 | 54 |
| 2020 December | 23 | 9 | 32 |
| 2020 November | 44 | 15 | 59 |
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| 2020 September | 60 | 9 | 69 |
| 2020 August | 28 | 4 | 32 |
| 2020 July | 52 | 4 | 56 |
| 2020 June | 36 | 7 | 43 |
| 2020 May | 46 | 0 | 46 |
| 2020 April | 51 | 9 | 60 |
| 2020 March | 53 | 11 | 64 |
| 2020 February | 199 | 25 | 224 |
| 2020 January | 35 | 10 | 45 |
| 2019 December | 45 | 5 | 50 |
| 2019 November | 36 | 1 | 37 |
| 2019 October | 35 | 5 | 40 |
| 2019 September | 32 | 10 | 42 |
| 2019 August | 31 | 6 | 37 |
| 2019 July | 51 | 12 | 63 |
| 2019 June | 34 | 2 | 36 |
| 2019 May | 55 | 11 | 66 |
| 2019 April | 20 | 15 | 35 |
| 2019 March | 52 | 10 | 62 |
| 2019 February | 93 | 10 | 103 |
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| 2018 December | 63 | 9 | 72 |
| 2018 November | 68 | 13 | 81 |
| 2018 October | 137 | 11 | 148 |
| 2018 September | 33 | 9 | 42 |
| 2018 August | 31 | 13 | 44 |
| 2018 July | 36 | 7 | 43 |
| 2018 June | 48 | 4 | 52 |
| 2018 May | 45 | 10 | 55 |
| 2018 April | 46 | 6 | 52 |
| 2018 March | 65 | 12 | 77 |
| 2018 February | 41 | 4 | 45 |
| 2018 January | 31 | 6 | 37 |
| 2017 December | 49 | 10 | 59 |
| 2017 November | 40 | 6 | 46 |
| 2017 October | 34 | 12 | 46 |
| 2017 September | 39 | 6 | 45 |
| 2017 August | 39 | 13 | 52 |
| 2017 July | 37 | 9 | 46 |
| 2017 June | 39 | 11 | 50 |
| 2017 May | 71 | 14 | 85 |
| 2017 April | 26 | 16 | 42 |
| 2017 March | 20 | 3 | 23 |
| 2017 February | 28 | 6 | 34 |
| 2017 January | 21 | 6 | 27 |
| 2016 December | 27 | 8 | 35 |
| 2016 November | 18 | 7 | 25 |
| 2016 October | 40 | 10 | 50 |
| 2016 September | 50 | 6 | 56 |
| 2016 August | 19 | 3 | 22 |
| 2016 July | 11 | 3 | 14 |
| 2016 June | 31 | 6 | 37 |
| 2016 May | 0 | 6 | 6 |
| 2016 April | 28 | 2 | 30 |
| 2016 March | 44 | 7 | 51 |
| 2016 February | 64 | 17 | 81 |
| 2016 January | 54 | 10 | 64 |
| 2015 December | 55 | 6 | 61 |
| 2015 November | 42 | 9 | 51 |
| 2015 October | 44 | 8 | 52 |
| 2015 September | 45 | 7 | 52 |
| 2015 August | 61 | 15 | 76 |
| 2015 July | 31 | 4 | 35 |
| 2015 June | 31 | 8 | 39 |
| 2015 May | 34 | 6 | 40 |
| 2015 April | 53 | 13 | 66 |
| 2015 March | 36 | 5 | 41 |
| 2015 February | 37 | 7 | 44 |
| 2015 January | 36 | 10 | 46 |
| 2014 December | 42 | 8 | 50 |
| 2014 November | 33 | 13 | 46 |
| 2014 October | 46 | 21 | 67 |
| 2014 September | 45 | 11 | 56 |
| 2014 August | 38 | 10 | 48 |
| 2014 July | 39 | 19 | 58 |
| 2014 June | 31 | 21 | 52 |
| 2014 May | 30 | 23 | 53 |
| 2014 April | 31 | 20 | 51 |
| 2014 March | 52 | 44 | 96 |
| 2014 February | 66 | 34 | 100 |
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