title: Cardiovascular disease: thinking beyond atherosclerosis.
abstract: A 56-year-old female patient was referred to our institution for atypical chest pain and palpitations. Physical examination, resting ECG and transthoracic echocardiogram were unremarkable. Stress perfusion scintigraphy was positive for anterior and apical myocardial ischaemia. A subsequent coronary angiogram showed no signs of atherosclerotic coronary artery disease; however, it revealed a coronary arteriovenous fistula and multiple other fistulous connections between the proximal segment of the left coronary artery and the pulmonary artery trunk. We present a rare case of a symptomatic coronary fistula that was percutaneously closed using an Amplatzer Vascular Plug, which resulted in clinical improvement and late fistula occlusion. This case report underlines the importance of thinking beyond atherosclerosis in the evaluation of chest pain syndromes. Moreover, it describes some of the angiogram caveats in assessing the coronary fistula number and morphology, as well as the cardiac-catheter potential for multiple pathway coronary artery fistulae closure.
authors.affiliation: Department of Cardiology, Coimbra's Hospital Center and University, Coimbra, Portugal. luisvpaiva@hotmail.com
authors.forename: Luis Manuel Vilardouro
authors.initials: LM
authors.lastname: Paiva
authors.forename: Marco
authors.initials: M
authors.lastname: Costa
authors.forename: Sergio
authors.initials: S
authors.lastname: Barra
authors.forename: Rui
authors.initials: R
authors.lastname: Providencia
mesh_terms: D001159:Arterio-Arterial Fistula / Q000150:complications / Q000175:diagnosis* / Q000601:surgery*; D002637:Chest Pain / Q000209:etiology; D017023:Coronary Angiography; D003324:Coronary Artery Disease / Q000150:complications / Q000175:diagnosis*; D003331:Coronary Vessels / Q000000981:diagnostic imaging; D003937:Diagnosis, Differential; D005260:Female; D006801:Humans; D008875:Middle Aged; D017202:Myocardial Ischemia / Q000209:etiology; D019919:Prosthesis Implantation; D011651:Pulmonary Artery / Q000000981:diagnostic imaging