ArticleFrontiers in cardiovascular medicine2026
A case report of iatrogenic coronarocameral fistula after surgical aortic valve replacement: multimodality diagnosis and intravascular ultrasound-guided left main intervention.
Article in Frontiers in cardiovascular medicine, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
Coronary fistulas draining into the left ventricle (LV) are exceptionally rare, and left main (LM) donor vessels almost invariably connect to right-sided structures rather than the LV. We report the case of a 69-year-old gentleman with prior mechanical surgical aortic valve replacement (SAVR) and a left internal mammary artery-to-left anterior descending (LIMA-LAD) bypass graft who presented with new-onset heart failure and a newly reduced left ventricular ejection fraction (∼40%). Transthoracic echocardiography demonstrated a normally functioning mechanical aortic valve, moderate functional mitral regurgitation and a color jet near the aortic root initially interpreted as mild paravalvular regurgitation. Coronary angiography revealed severe, calcified LM ostial and bifurcation disease together with a discrete contrast communication from the LM to the LV. Three-dimensional transthoracic echocardiography reclassified the jet as a coronary fistula (LM-to-LV) anatomically distinct from the prosthetic sewing ring, while intravascular ultrasound (IVUS) confirmed heavy ostial/bifurcation calcification and a focal opening in proximal LM resembling a side-branch, corresponding to the fistulous segment. IVUS-guided LM-LCx percutaneous coronary intervention with two drug-eluting stents resulted in optimal stent expansion and apposition, with preserved competitive LAD flow via the LIMA graft, while the LM-to-LV communication remained angiographically modest. To our knowledge, this is the first reported iatrogenic LM-to-LV fistula after mechanical SAVR and highlights the pivotal role of multimodality imaging in distinguishing LM originating fistulas from paravalvular regurgitation or aorto-LV tunnels, and in guiding management by prioritizing safe LM revascularization while deferring targeted fistula closure pending assessment of shunt burden and clinical impact.
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