A coronary fistula diagnosed in the eighth decade of life: The utility of non-invasive methods in the selection of treatment approach.

A 77-year-old woman was referred to our Department of Cardiology because of exacerbation of chest pain and decreased exercise intolerance. No acute ischemic electrocardiography changes were seen in an electrocardiogram recorded on admission. An exercise test was terminated at 7 METS because of shortness of breath without evidence of ischemia. The patient was referred for a coronary angiography which showed a coronary artery fistula filling from the left anterior descending (LAD) artery and resulting in a large inflow to the main pulmonary artery, without other significant coronary lesions. Transthoracic echocardiography showed a coronary artery fistula draining to the main pulmonary artery. Coronary steal was suspected and coronary flow reserve was evaluated in LAD, showing normal values for age. Due to the overall clinical picture, with the predominance of heart failure symptoms and the lack of significant abnormalities of flow reserve in LAD, medical therapy was selected. The patient remained free from cardiovascular symptoms at 6-month follow-up.