Letter to the Editor Dual coronary fistulas complicated with significant left to right heart shunt in an elderly patient Kai-Hang Yiu ⁎, Stephen-Wailuen Lee, Hee-Hwa Ho, Hon-Wah Chan, Hung-Fat Tse Division of Cardiology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China abstract article info Article history: Received 14 May 2009 Accepted 24 May 2009 Available online 13 June 2009 Keywords: Dual coronary fistulas Left to right heart shunt Dual coronary artery fistula is a rare clinical entity and their clinical significance remains unknown. We hereby report a case of right coronary artery and left anterior descending artery fistula to pulmonary artery complicated with clinical significant left to right shunt (1.6:1) who remained clinically well at the age of 85 without percutaneous or surgical closure. © 2009 Elsevier Ireland Ltd. All rights reserved. 1. Introduction Coronary artery fistula is usually an incidental finding during coronary angiography with an incidence of 0.1–0.2% [1] and dual coronary fistula occurred in 5% amongst this group of patients [2] with unknown long term outcome. We hereby report a case in an old male at the age of 81 with right coronary artery and left anterior descending artery — pulmonary artery fistula complicated with significant left to right heart shunt documented by right heart catheterization. 2. Case report An 81 year old gentleman presented with atypical chest pain and positive treadmill was admitted for elective coronary angiogram. Physical examination was unremarkable and chest X-ray was normal. Coronary angiogram reviewed no coronary artery stenosis. Two large fistulas originating from the proximal right coronary artery and prox- imal left anterior descending artery drained into the pulmonary artery was noted [Fig. 1]. Right heart catheterization revealed no pulmonary hypertension with right ventricle pressure 30/1 mm Hg. A significant step up of oxygen saturation was noted between the right ventricule (SaO2 66.6%) and the main pulmonary artery (SaO2 77.1%). The pul- monary to systemic flow ratio was 1.61/1. In view of no evidence of pulmonary hypertension and right ventricle impairment of echocar- diogram, surgical ligation of fistulas was not performed. Patient was followed up regularly without developing any major adverse cardio- vascular events and remained clinically fit at the age of 85. 3. Discussion Coronary artery fistula (CAF) is an uncommon entity reported to be 0.1–0.2% in angiographic series [1]. The most common proximal communication arises from right coronary artery followed by left anterior descending artery and the distal communication most com- monly occurred in the pulmonary artery [1]. Dual coronary artery fistula occurred infrequently which mostly arise from the right cor- onary artery and left descending artery [2–4] which was also seen in our case. Coronary fistula most often remained asymptomatic without clin- ical consequences but large fistula may lead to myocardial ischemia, heart failure, infective endocarditis or even rupture [1].While most of coronary fistula had no significant left to right shunt (b 1.5:1) [1], previous report has noted a significant shunt in a patient with dual coronary fistula which was managed conservatively [5]. The risk of surgical closure has been reported to be low [6], however the clinical and long-term outcome of this group of patients remained unknown and no study has been conducted previously to assess the indication and optimal time for surgical intervention. Although the current patient suffered from clinical significant left to right shunt and myo- cardial ischemia secondary to dual coronary fistulas, he remained clinically well at the age of 85 albeit treated conservatively. Acknowledgement This study was not supported by any funding. The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology [7]. International Journal of Cardiology 149 (2011) e108–e109 ⁎ Corresponding author. Tel.: +852 2855 3111; fax: +852 2818 6304. E-mail address: khkyiu@hotmail.com (K.-H. Yiu). 0167-5273/$ – see front matter © 2009 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2009.05.048 Contents lists available at ScienceDirect International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard