Bilateral coronary artery fistulas with progressive aortic regurgitation presenting as persistent atrial fibrillation, acute heart failure and pulmonary hypertension: a case report

Coronary artery fistula (CAF) represents a rare cardiovascular anomaly, defined by an abnormal connection between one or more coronary arteries and the cardiac chambers or other intrathoracic vessels. Most CAFs are congenital, single, small, and asymptomatic, often discovered incidentally. Nonetheless, some cases possess potential clinical implications, including arrhythmia, congestive heart failure, cardiomyopathy and pulmonary hypertension. Furthermore, CAFs may coexist with other congenital cardiac anomalies, posing significant diagnostic and management challenges. This case report describes a 50-year-old male patient with progressive left atrial dilation and aortic regurgitation, who subsequently developed persistent atrial fibrillation, acute heart failure, and pulmonary hypertension. Incidentally, contrast-enhanced computed tomography and subsequent coronary angiography confirmed the presence of bilateral coronary-to-pulmonary artery fistulas. Stress myocardial perfusion scintigraphy demonstrated significant myocardial ischemia in the territory of the left anterior descending coronary artery. Right heart catheterization indicated combined post-and precapillary pulmonary hypertension and a moderate left-to-right shunt. In addition to receiving guideline-directed medical therapy, the patient underwent atrial fibrillation catheter ablation and simultaneous transcatheter CAFs closure. During a one-year follow-up period, the patient maintained sinus rhythm and reported overall well-being. Echocardiography and cardiac magnetic resonance imaging revealed significant recovery from adverse cardiac remodeling. This case underscores the significance of comprehensive cardiac evaluations in patients with atrial fibrillation and/or heart failure, as atypical findings can substantially influence diagnoses, management, and outcomes. Furthermore, given the complex interrelationship between CAFs, aortic regurgitation, atrial fibrillation, and heart failure, this report highlights the necessity for individualized treatment strategies that integrate pharmacological, interventional, and surgical approaches.