An Unusual Presentation of Coronary Artery Fistula in Athlete - Case Report

Abstract

A 32-year-old active cyclist was referred fo r the evaluation because of syncope he had performed in preseason. He was found to be normostenic, acyanotic, normotensive with clear lungs and a regular pulse of 60 bp m, with normal dual heart sounds and a grade Levine 2/6 continuous diastolic murmu r in the second intercostal space of the left parasternal area. He had no family history of premature card iac death and his lipids were normal. Rest ECG showed a regular sinus rhythm of 62 bp m with inco mplete right bundle branch block and no significant ST-T changes. A transthoracic ECHO in parasternal short-axis view revealed an anomalous colour flow jet in diastole arising fro m the lateral wall into the main pulmonary artery and coronary artery fistula with non-significant left -to-right shunt (Qp/Qs ratio 1.2).came under suspicion. In contrast, it has not been confirmed clearly by the transoesophageal ECHO. Coronary angiography was without coronary stenosis and confirmed a 'serpentine' anomalous drainage supposedly from left anterior descending artery to the main pulmonary artery. A complex anato my of sacculary dilated fistula that originates fro m the pro ximal left anterio r descending artery and drainages the main pulmonary artery was showed in detail by a 64 slice MDCT scanning. Myocardial Tc-99m Myoview perfusion SPECT imag ing showed no perfusion defects in maximal physical stress and follo w-up without intervention was suggested. In addition, due to the results of holter ECG monitoring, head-up tilt testing, carotid sinus massage and programmed atrial stimulat ion syncope was concluded as vasovagal, but its nature still remains discussible. After a three year follow-up patient remains asympto matic and recently performed control myocardial perfusion SPECT showed no signs of stress related myo cardial ischemia. In conclusion, several imaging techniques are needed for an accurate diagnosis of coronary fistula and for the suggestion of proper further management. In some cases syncope may be the first man ifestation of CAF, but it is still unclear if it is directly related to the coronary anomaly.