An Anomalous Right Coronary Artery Draining into the Left Ventricle Through a Fistula

Background: Of the three main epicardial coronary arteries, the right coronary artery, left anterior descending artery, and the left circumflex artery, there are many variables between individuals regarding arterial course, distribution of side branches, and termination points. The term ‘Coronary Artery Anomaly’ (CAA) is reserved for congenital alterations in origin or course of the epicardial arteries that occur in less than 1% of the population. While the majority are asymptomatic, such anomalies can significantly increase the risk of myocardial ischemia and sudden cardiac death. With the increasing use of Coronary Computed Tomography Angiography (CCTA), the rate of detection of anomalous coronary arteries is increasing every year. The concurrent presence of a coronary cameral fistula further escalates clinical complexity requiring a multidisciplinary approach to management. Case Report: A 61-year-old female with a past medical history of hypertension, hypothyroidism, migraine, Non-Sustained Ventricular Tachycardia (NSVT), and Supraventricular Tachycardia (SVT), presented to the emergency department with chest pain and palpitations. Coronary angiography was performed revealing a large Right Coronary Artery (RCA) with a proximal branch giving rise to the Left Circumflex Artery (LCX), with an additional branch supplying the Left Anterior Descending (LAD) territory. The RCA and LCX arteries terminated distally in the left ventricular cavity forming a coronary cameral fistula. No flow-limiting stenosis was observed. Intervention versus medical management was discussed with a multidisciplinary team, and the decision was made to proceed with medical management. The patient’s symptoms improved with the medical management. Conclusion: A thorough diagnostic evaluation and a multidisciplinary approach in managing rare coronary anomalies are critical. Medical management, risk factor modification, and regular follow-up are essential components of long-term care for patients with complex coronary artery anomalies.