P167 ECG ABNORMALITIES AND DOUBLE CORONARY FISTULA

Abstract Coronary artery fistula (CAF) is defined as anomalous communication between coronary arteries and cardiac chamber or a major thoracic vessel. CAF are a rare coronary anomaly, mostly congenital, first described by Krause in 1856. In literature the incidence in general population is approximately 0,002%. Detection of CAF during coronary angiography is usually accidental. In 50% of cases CAF originate from right coronary artery, in 30% they originate from LAD, while in the rest of the percentage CAF originate from left circumflex artery. CAF drain into low–pressure chamber (right ventricle or right atrium, superior Vena Cava or pulmonary artery). We can distinguish CAF into little or medium sized, usually with silent clinical course, and large sized CAF, with variable clinical signs, depending on the extent of the shunt and on the hemodynamic overload of the receiving chamber. We describe the case of a 57 y.o woman with hypertension, admitted for femur fracture. ECG showed bifasic T waves in the anterior leads, already described in a previous ECG. Normal systolic function and no valvular defect were found on the echocardiogram. Patient was asymptomatic. Coronary angiography documented normal coronary arteries, with a double coronary fistula: the first from a septal branch of posterior descending and the second one from distal branches of the first diagonal. Even if CAF have often a favorable clinical course with no relevant consequences for the patient, it’s crucial to obtain more information about their functional implication and their anatomic connections. Indeed, rare cases of sudden cardiac death have been described in patients with CAF involved in myocardial ischemia based on the theft syndrome mechanism. Echocardiographic evaluation of the patient to detect associated congenital abnormalities, pressure overload of the receiving chambers and the extent of the shunt on the coronary angiography are crucial for the proper management of CAF. In the case described above we decided to optimize therapy adding beta–blocker (to reduce the overload caused by the two coronary fistula).