Unusual presentation of a huge right coronary artery fistula; Technical issues with device closure

Coronary artery fistula (CAF) is considered an embryologic persistence of primitive intra-trabecular spaces which allow the developing coronary artery to communicate with the other cardiac chambers or vascular structures. It is observed in 0.05–0.25% of coronary angiographic studies, most of which drain into a right heart chamber or into the pulmonary artery, while a congenital right coronary artery (RCA) into a left heart chamber is less frequent.5 In this study, we describe an unusual case treated by closure device in the right coronary artery fistula to the left ventricle, and associated literature is reviewed. A 40-year-old female presented with chronic cough, otherwise asymptomatic. Echocardiogram revealed unusual flow into the LV with mild LV dilatation. A 64 multi-slice CT scan confirmed the presence of a huge right coronary opening with a fistula into the left ventricle. The decision was to close this fistula with device through the RCA into the left ventricle. The management of this unusually large fistula is described with focus on technical issues with device closure.