Coronary artery fistula

This is a case of a 14-year-old boy who attended the emergency department with fever, cough, and arthralgia. Examination revealed hepatomegaly and a continuous murmur. Blood cultures were positive on three separate occasions for meticillin-sensitive Staphylococcus aureus, and a diagnosis of infective endocarditis, with an intra-atrial thrombus complicating a coronary artery fistula, was made. The intracardiac thrombus was functioning as a septic nidus, and the patient had cavitating lung nodules likely representing septic emboli. The patient underwent thrombolytic therapy to eradicate the thrombus and recovered following a prolonged course of intravenous antibiotics and low-molecular weight heparin. Several months later, he electively underwent transcatheter device closure of the coronary artery fistula. This case discusses the definition and types of fistulae; the pathophysiology, presentation, and complications associated with this condition; the investigations and diagnosis; and finally the management options for patients with coronary artery fistulae. The nuances involved in the management of these cases are discussed, including the debate regarding indications for closure.