We present an unusual case of a 73 old male, who presented with dysnoea on exertion, NYHA Class III and atrial fibrillation. Transesophageal echocardiography revealed a large cystic structure around the left atrium. A computed tomogram (CT) of the thorax and left coronary arteriogram revealed a giant fistula between the left circumflex coronary (LCA) and right pulmonary artery (PA), with a left-to-right shunt ratio of 1:1,2. In addition, the left anterior descending artery (LAD), which arose directly from the fistula, appeared to have a significant stenosis at its origin.
The patient underwent an uneventful surgical closure of the fistula, a left internal mammary artery bypass to the LAD and left atrial cryoablation. A postoperative CT of the thorax confirmed that the fistula was successfully closed. However, the patient continued to experience breathlessness after discharge, which gradually increased in intensity to NYHA Class III over a period of 6 months. Serial echocardiographies showed that the patient had developed progressively worsening mitral regurgitation. A repeat coronary angiography revealed that the LIMA-LAD bypass was occluded due to competitive flows in the LAD, which showed no stenoses at the present time. In addition, the small left circumflex artery was also occluded.
The left circumflex artery was considered too small for bypass surgery, and hence was not grafted. The patient underwent a minimally invasive mitral valve repair (MVR) resulting in disappearance of MR at discharge echocardiography.
