Asymptomatic Coronary to Left Ventricle Fistula with Coronary Artery Ectasia Managed Conservatively: A Case Report

Coronary artery fistula with coexisting coronary artery ectasia is a rare anomaly, and optimal management for asymptomatic cases remains unclear. We report a 52-year-old Cambodian man incidentally found to have a right coronary artery to left ventricular (LV) fistula with diffuse coronary artery ectasia during a routine health check-up. He was asymptomatic with normal vital signs and unremarkable physical findings. Transthoracic echocardiography revealed preserved LV function with mildly reduced global longitudinal strain (−13.4%), right coronary artery dilatation and abnormal diastolic flow into the LV. Coronary CT angiography confirmed a large right coronary artery ectasia and a terminal fistulous orifice draining into the LV, without thrombus. The pulmonary:systemic flow ratio by transthoracic echocardiography was 1.03, indicating haemodynamically insignificant shunting. After multidisciplinary discussion, conservative treatment was selected. At follow-up, the patient remained asymptomatic. This case highlights that conservative management may be reasonable for select asymptomatic patients with coronary artery fistula and coronary artery ectasia. Long-term follow-up is valuable to better define management strategies for similar cases.