Coronary artery fistula features associated with clinical symptoms in adults with non coronary artery disease detected with coronary computed tomography angiography
Authors: Liemena HA , Atmadikoesoemah CA , Rahimah AF , Sahara E , Kasim M 
Published: July 2021

Abstract

Funding Acknowledgements
Type of funding sources: Public hospital(s). Main funding source(s): National Cardiovascular Center Harapan Kita, Jakarta, Indonesia

Background
Coronary artery fistula (CAF) is rare coronary artery anomaly (&lt;1% in general population). It is often diagnosed accidentally during coronary angiography. Most of CAF cases have no clinical significance, however, some may present with hemodynamic instabilities, requiring invasive or surgical intervention. Recently, coronary computed tomography angiography (CCTA) has been increasingly used to detect CAF at higher rates. Correlation between CAF and significance of clinical presentation, however, remains unclear.

Purpose
To evaluate association of CAF features with any symptomatic trends present in non coronary artery disease (CAD) patients.

Methods
This was a single-center, observational, analytic cross-sectional study. A total 45 cases of CAF with no documented CAD or non-significant stenosis CAD diagnosed by coronary CT angiography were collected from 10,175 consecutive patients in National Cardiovascular Center Harapan Kita spanning 5-years from January 2015 to December 2019. The imaging findings, morphologic features and relevant clinical history were recorded and analyzed.

Results
The prevalence of CAF determined with CCTA in our study was 0.44%. Among 45 patients with CAF, thirty (67%) were female. Mean age was 49.4 ± 12.9 years. Most common symptoms reported, in decreasing frequency, were chest pain (60%), dyspnea (22.2%), palpitation/arrhythmia (11.2%), syncope (4.4%) and general weakness (2.2%). Most common site of CAF origin was the left anterior descending artery (66.7%), followed by right coronary artery (51.1%). The fistula most commonly terminated in the main pulmonary artery (75.5%). The CAF size, in descending order, were small (35.6%), medium (33.3%), and large (20%). Mixed and multiple CAF were presented in 5 cases (11.1%). Aneurysm formation were identified in 10 cases (22.2%). CAF were mainly associated with congenital atrial and ventricular septal defects (6.7%; 4.4%, respectively). Other coexistent cardiac abnormalities presented with CAF were pulmonary hypertension (8.9%), infective endocarditis (4.4%), and pericardial effusion (2.2%). Large-sized CAF was significantly associated with chest pain and palpitation/arrhythmia (p = 0.017; p = 0.003, respectively). Aneurysm formation revealed to be significantly associated with chest pain and palpitation/arrhythmia (p = 0.044; p = 0.006, respectively) as well. Mixed and multiple CAF were significantly correlated with syncope (p = 0.003). CAF with concomitant cardiac diseases (congenital heart disease, pulmonary hypertension, valvular heart disease) were significantly associated with symptoms of chest pain and palpitation/arrhythmia as compared to isolated CAF only (p = 0.004; p = 0.007, respectively).

Conclusion
CAF features (large-sized, mixed and multiple, aneurysmal and presence of concomitant cardiac disease) were associated with significant trends of clinical symptoms in adults without CAD.