Giant Left Circumflex Coronary Fistula to the Right Atrium

A 49-year-old man with multiple coronary risk factors, including diabetes mellitus, hypertension, and hyperlipidemia, was referred for coronary angiography for evaluation of mild dyspnea on exertion and atypical chest pains. An exercise nuclear stress test demonstrated mild, reversible ischemia in the mid and distal inferior wall. The patient subsequently underwent cardiac catheterization, which demonstrated a giant coronary arterial-venous (A-V) fistula arising from a markedly dilated and tortuous circumflex artery (Figure 1). The vessel course could not be well delineated because of its tortuosity and the inability to fully opacify this structure with contrast. The other primary epicardial coronary arteries were angiographically normal. A small left-to-right shunt was detected, with Qp/Qs=1.29. Figure 1. Coronary angiography (anteroposterior view) showing severely dilated left circumflex artery in loops with poor contrast opacification.The patient was referred …