Coronary artery to pulmonary artery fistula in an older adult: diagnostic and treatment insights

Coronary artery fistulas (CAFs) are rare vascular anomalies involving an aberrant connection between a coronary artery and a cardiac chamber, great vessel, or other vascular structure. A thorough understanding of the unusual anatomy of these fistulae is important for recognizing their effects on the heart and guiding appropriate treatment decisions. While often congenital and asymptomatic, they may present later in life with nonspecific symptoms such as chest pain or dyspnea. Recognition of CAFs, particularly in elderly patients, requires a high index of suspicion and a thorough understanding of their pathophysiology, anatomic variability, and potential hemodynamic consequences. Advanced imaging techniques, especially coronary computed tomography angiography (CCTA) increasingly enable accurate, non-invasive identification of these anomalies and guide subsequent management. We present a case of a 72-year-old woman with recurrent chest discomfort who was incidentally diagnosed with a left anterior descending artery to pulmonary artery fistula on CCTA, subsequently confirmed with coronary angiography. A comprehensive workup revealed no evidence of ischemia or hemodynamic compromise. After multidisciplinary discussion and shared decision-making, a conservative, pharmacologic approach was selected, with plans for serial imaging surveillance in accordance with guideline recommendations. This case underscores the importance of individualized management strategies for CAFs, particularly in older adults with atypical presentations. It highlights the vital role of multimodal imaging in diagnosis and surveillance, and the value of a thoughtful, patient-centered approach when interventional procedures may not be clearly warranted. As awareness and detection of CAFs continue to grow, further research is needed to guide long-term management and inform evidence-based care.