Multimodality Imaging in Management of Circumflex Artery to Superior Vena Cava Fistula

A 55-year-old gentleman presented to his local hospital with troponin positive chest pain.Angiography revealed multi-vessel coronary artery disease as well as an ectatic circumflex with an unusual course.(Figure 1A).A CT coronary angiogram suggested a circumflex coronary artery to superior vena cava fistula (Figure 1B). 1Intra-operative transesophageal echocardiography demonstrated flow from an aberrant left circumflex artery into the superior vena cava as well as ischaemic cardiomyopathy and mitral regurgitation (Figure 2, Video).A sternotomy was performed and cardiopulmonary bypass established.Coronary artery bypass was performed to the left anterior descending artery and two obtuse marginal branches.The fistulous portion of the circumflex was ligated (figure 3).The mitral valve was repaired with annuloplasty and cleft closure.The patient made an uneventful recovery.At follow-up, there was resolution of his pre-operative symptoms as well as improved left ventricular function and no mitral regurgitation on his postoperative echocardiogram.