a coronary artery fistula ( caf ) is an abnormal communication between one of the coronary arteries and a cardiac chamber or vessels , including the coronary sinus , pulmonary artery , or superior vena cava.1)2)3 ) caf is involved in 0.002% of general population and accounts for 0.4% of all cardiac malformation.4 ) caf mostly drains into the venous structures of circulation , such as the right - sided chambers , pulmonary artery , coronary sinus and superior vena cava , but drainage into the left - sided chambers is less frequent.5 ) we present a case of caf which is originated from left coronary artery and drained into left ventricle .
a 48-year - old male presented with abdominal pain that had lasted for 2 months .
he had no cardiovascular risk factor , and no cardiovascular symptom such as chest pain or dyspnea .
preoperative electrocardiography was within normal limit , and chest x - ray showed no pathologic abnormality .
he was consulted to cardiovascular department because surgeon heard a continuous cardiac murmur and ordered echocardiography for a preoperative evaluation .
the mitral inflow e / a ratio was 1.63 , and e / e ' ratio was 12.0 .
however , there was abnormal color flow within left ventricle predominantly during diastole ( fig . 1 , supplementary movie 1,2 , 3 , 4 ) .
the maximal velocity of blood flow draining into left ventricle was approximately 3.0 m / s . in short - axis great arterial view , left coronary artery appeared dilated .
multiple tortuous dilated vascular structures with internal blood flows disclosed by color doppler image were also found around left ventricular myocardium . especially , dilated large echo - free vascular structure was detected in the apical area .
the connection between those dilated vascular structures and left coronary artery was suspected , but clear visualization of the connection was limited in 2-dimensional echocardiography .
coronary artery computed tomography ( ct ) scan was performed to confirm the pathologic anatomy of these abnormal findings .
coronary ct revealed markedly dilated ( up to 16 mm ) and serpentine whole left coronary arteries ( fig .
2 ) . the left anterior descending artery was communicating with left circumflex artery at the apical posterior epicardium , and was directly connected to the basal posterior side of left ventricular cavity ( fig .
since the patient had no cardiovascular symptom , he underwent laparoscopic cholecystectomy without specific treatment of caf .
caf communicating with the cardiac chambers are called coronary cameral fistula , as in our case .
however , the incidence of coronary cameral fistula is very low and coronary cameral fistula involving left ventricle has been very rarely reported.4)5 ) this case is also unique because almost whole left coronary artery was dilated and looked like cystic lesion in the apical portion , which could be clearly detected by transthoracic doppler echocardiography .
the majority of coronary cameral fistula ( up to 90% ) drains into the right - sided chambers of the heart , while only 10% of coronary cameral fistula shows communications with the left - sided chambers or both left and right - sided chambers.6 ) doppler echocardiography is a good screening imaging tool for the diagnosis of caf , but evaluation of whole anatomy of caf can be best visualized by coronary ct image .
chest pain , exertional dyspnea and fatigue may develop , but many patients do not suffer from any symptoms.7 ) the mechanism of symptoms appeared to be coronary steal phenomenon and diastolic overload.8 ) the most common complication is myocardial ischemia due to coronary steal phenomenon which occurs in 15% of patients with caf.9 ) congestive heart failure and arrhythmia could be caused by excessive loading of cardiac chambers .
intravascular thrombosis , infective endocarditis , and rarely hemopericardium due to rupture of aneurysmal coronary artery might be complications .
surgical closure of caf may have benefit for the patients with large , hemodynamically significant caf.10 ) there were several reasons for not doing any surgical interventions for this patient .
first , this pathology was incidentally found without any cardiovascular symptom , and may carry only mild risk in undergoing laparoscopic surgery . therefore , the first thing we had to do for this patient was to let the surgeon not to postpone this necessary surgery because of the cardiac problem .
second , good functional status of this patient indicates low possibility of coronary steal causing myocardial ischemia due to this pathology .
lastly , surgical treatment for this coronary cameral fistula was not technically easy , because almost entire portion of the coronary artery was dilated as noticed in coronary ct .
the parasternal long axis view revealed abnormal color flow within left ventricle predominantly during diastole .
the parasternal short axis view revealed diastoledominant abnormal color flow draining from posterior left ventricular wall . dilated large vascular structure was detected in the apical area .
abnormal vascular structure was originated from basal posterior wall and drained into the left ventricular cavity .
 we present a case of 48-year - old male who presented with coronary artery fistula draining into left ventricle . 
 transthoracic echocardiography showed abnormal blood flow draining into left ventricle , with enlarged coronary arteries and multiple vascular structures around ventricular myocardium . 
 coronary computed tomography revealed dilatation of entire left coronary artery which was wrapping around left ventricle , and draining into the posterior side of left ventricle . 
 he did not undergo any invasive treatment , because he was not symptomatic . 
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