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Background Coronary fistula are rare, and often present in early adulthood with symptoms of right heart overload from left to right shunting, or ischemia in the distal coronary bed due to coronary steal. Case Summary A 73 years-old lady with prior history of supraventricular tachycardia, dyslipidemia and a right coronary artery to coronary sinus (RCA to CS) fistula, presented with progressive angina. She did not have evidence of ischemia in the RCA territory on nuclear imaging, and cardiac computed tomography (CT) did not show coronary artery disease but revealed a significantly dilated coronary sinus and coronary venous tree. She was found to have CS ostial stenosis, and, under transesophageal echocardiographic (TEE) guidance, underwent successful balloon angioplasty of the CS ostium, with decompression of the coronary venous circulation and resolution of her angina. Discussion Coronary fistula draining to the CS are rare, and association with CS ostial stenosis has been reported very infrequently. CS ostial stenosis can cause elevated coronary venous pressure, leading to decreased global coronary perfusion and symptoms of angina or heart failure. Previous case reports of coronary fistula and CS ostial stenosis were treated with either medical therapy or surgery, and our case is the first to our knowledge to report successful percutaneous treatment.

An unusual pair: coronary artery fistula and coronary sinus ostium stenosis as a cause of refractory angina