Cath Lab DigestEighty Years Undetected: A Congenital Coronary Cameral Fistula Without Significant Shunt

An 80-year-old male lived his entire life with a large coronary cameral fistula connecting the left anterior descending artery to the right ventricle without hemodynamic consequences. Right heart catheterization showed Qp:Qs ratio of 1.0 with no significant shunt despite angiographic coronary steal.

🔬 CLINICAL CONSIDERATIONS

• Coronary cameral fistulae occur in <1% of population, incidentally found in 0.2% of angiographic studies, most from right coronary system
• Angiographic coronary steal doesn’t confirm hemodynamic significance: right heart catheterization with oxygen saturation step-up required for shunt quantification
• Conservative management appropriate for asymptomatic patients without chamber enlargement, significant shunt, or pulmonary hypertension regardless of fistula size
• Intervention indicated only for symptomatic fistulae causing ischemia, volume overload, arrhythmias, or endocarditis risk with transcatheter closure preferred

💊 PRACTICE APPLICATIONS

• Obtain right heart catheterization with oximetry when coronary fistulae identified on angiography
• Assess for chamber dilation and pulmonary hypertension on echocardiography before intervention decisions
• Continue medical management with beta blockers and antiplatelet therapy for hemodynamically insignificant fistulae
• Reserve transcatheter closure for symptomatic patients or those with Qp:Qs >1.5 or chamber enlargement

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