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A 63 y/o male with a past medical history of hypertension, chronic obstructive pulmonary disease, and obesity was admitted to an outside hospital for an abdominal incisional hernia repair and cholecystectomy. Post-operatively he developed shortness of breath (SOB) and multiple runs of paroxysmal atrial fibrillation. A CT scan was negative for pulmonary embolism, but showed a left anterior descending (LAD) coronary artery to main pulmonary artery (MPA) fistula. He was transferred to our facility for further management.Upon transfer, the patient was able to ambulate without SOB and no arrhythmias were recorded on telemetry. He underwent a stress echocardiogram-a dobutamine stress echocardiogram was performed as the patient had limited functional capacity on the initial treadmill study in part due to his recent surgery. It showed normal left and right ventricular function with an ejection fraction of 60%, at rest. During pharmacologic stress, his peak heart rate was suboptimal only reaching 67% of his predicted maximum heart rate. His EF improved to 65% without evidence of any regional wall motion abnormalities.Given his initial presentation at the outside hospital and his current clinical status at our institution and no objective signs of cardiac limitation a right and left heart catheterization was performed. The right heart pressures were slightly elevated. A shunt run showed no step up in oxygen saturation (Table 1) suggesting similar pulmonary and systemic flows. A left heart catheterization was then performed showing no significant coronary artery disease but demonstrated a fistula originating at the mid LAD connecting to the MPA, with only a small connection between the aneurysmal fistula and the MPA (Image 1). Intravascular ultrasound (IVUS), with a Volcano 5F Eagle Eye, measured the mid LAD diameter at 7 mm 2 , compared to a 13.2 mm 2 diameter in the proximal LAD, with a 37.3% plaque burden. The os of the fistula measured 3.4 mm 2 .Given no step in oxygen saturation and only minimal flow into the MPA, further testing for ischemia was performed by placing a Volcano Verrata 0.014 inch wire was positioned distal to the LAD fistula and fractional flow reserve (FFR) was performed. The baseline resting pressure difference was 0.88. With intravenous adenosine infusion at 140mg/kg/min the pressure gradient increased to 0.84. Based on these findings-no oxygen step up on shunt run and an FFR measurement >0.80 closure of the coronary fistula.Coronary artery fistulae are a rare congenital anomaly that often present with nonspecific symptoms causing a wide range of problems including shunting resulting in myocardial ischemia, LV failure, pulmonary hypertension and arrhythmias. Current national guidelines state, "small to moderate coronary arteriovenous fistula in the presence of documented myocardial ischemia, arrhythmia, otherwise unexplained ventricular systolic

Background: ST-segment elevation myocardial infarctions (STEMI) are uncommon presentations of coronary artery anomalies and pose challenges in the emergent setting of percutaneous coronary interventions. We describe an extremely rare case of left main coronary artery (LMCA) originating off the right coronary artery (RCA) in a patient who presents with STEMI and was found to have Medina 1,1,1 lesion at the origin of the anomalous (LMCA). Case Presentation: An 81-year old male, with a past medical history significant for aortic stenosis and hyperlipidemia, presents to the emergency room for substernal non-radiating chest pressure. His electrocardiogram showed ST segment elevations in inferior and anterior leads. He was taken emergently to the cardiac cath lab. Coronary angiogram revealed a single right coronary ostium with an anomalous LMCA to mid left anterior descending (LAD) artery via dual insertion within a myocardial bridge. There was severe 90% Medina 1,1,1 bifurcating proximal RCA stenosis and 90% proximal LMCA stenosis. The entire left coronary system was fed by the anomalous LMCA, which was inserted into the mid-LAD in a dual insertion, between which there was a myocardial bridge. Cardiothoracic surgery team was consulted, and decision was made to pursue coronary artery bypass grafting (CABG). An intra-aortic balloon pump was placed via right femoral artery and patient was taken for emergent surgery, where he underwent 3 vessel CABG (left internal mammary artery to LAD, saphenous venous graft to obtuse marginal branch and posterior descending artery). Discussion: A broad spectrum of coronary anomalies have been reported, but their incidence in STEMI is rare. We discuss a very rare anomaly in which the entire left coronary system branches off the RCA, and culprit lesion was found to be a Medina 1,1,1 lesion. We aim to add to the sparce data pool of STEMI management in patients with anomalous coronary arteries.

With remarkable advancement in technology and clinical research, implantable cardioverter defibrillators (ICDs) have replaced antiarrhythmic drugs as the preferred modality for both primary and secondary prevention of arrhythmic deaths. However, concomitant use of antiarrhythmics in patients with ICDs remains common, often for prevention or reduction of appropriate and inappropriate shocks caused by ventricular and supraventricular arrhythmias, respectively. The role of empiric antiarrhythmic therapy in this patient population remains less clearly defined, with conflicting information from various small randomized trials. Use of antiarrhythmic drugs in the ICD patient population not only can cause potentially serious side effects but can also interact or interfere with the ICD device function. In addition, the effect on survival in patients with ICDs is not well characterized. Given the many potential side effects, drug-device interactions, unclear survival effect, and lack of convincing clinical data supporting its use, empiric antiarrhythmic therapy in the ICD patient population cannot be recommended at this time.