Exercise‐induced ventricular arrhythmia due to bilateral coronary to pulmonary artery fistulas

Abstract

Ischemic polymorphic ventricular ectopy was documented during exercise testing in a 65‐year‐old Caucasian male patient. Coronary angiogram revealed four coronary to pulmonary artery fistulas (CPAFs) originating from the right and left coronary artery, leading to myocardial ischemia due to steal phenomenon. The three dominant fistulas were coiled percutaneously, while one small fistula was left untreated. During follow‐up, no significant residual ventricular arrhythmia was detected.

Fistulous communication between the left main coronary artery and the pulmonary artery as a cause of angina

“…More than half of patients with CPAF exhibited no related symptoms [ 12 ]. The clinical symptoms are attributed to the “coronary steal phenomenon”, which can lead to symptoms such as angina or dyspnea even in the absence of stenosis [ 13 ]. The term “coronary steal” emerged in 1967 as a vivid description, drawing a parallel to the term “subclavian steal” introduced in an editorial in 1961 [ 14 , 15 ].…”

“…Notably, a murmur was the most frequent finding during physical examination (37%) [ 10 ]. Arrhythmias, such as polymorphic ventricular ectopy, have also been reported [ 5 , 13 ]. Most abnormalities of the coronary arteries are incidentally detected during coronary angiography [ 4 , 5 ].…”

“…Transcatheter intervention is suitable only in cases where the morphology is simple, and the choice of the closure device is based on the anatomical characteristics of the fistula [ 9 ]. Interventional coiling is also an option [ 13 ]. Therefore, in cases of CAFs with a proximal origin, a single draining site, non-tortuous characteristics, extra-anatomic terminations, absence of comorbid cardiovascular disease, or involvement of older high-risk patients, percutaneous transcatheter closure should be considered [ 5 ].…”