Case report: Unusual cause of chest pain in an elderly male

A 72-year-old man presented to the outpatient clinic with symptoms of chest pain and dyspnoea on exertion (NYHA III) for past two months. Physical examination was unremarkable with normal first and second heart sounds. Unfortunately, the valsalva maneuver was not performed as no murmur was appreciated on clinical examination. Echocardiogram showed small sized LV cavity with asymmetrical septal hypertrophy in the mid segments measuring 22 mm, normal LV systolic function, producing mid cavity gradients of 50 mm of Hg, suggestive of hypertrophic cardiomyopathy. Cardiac magnetic resonance imaging (CMR) was performed that confirmed hypertrophic cardiomyopathy (HCM). A contrast enhanced CT angiogram (CTA) was done that showed coronary artery fistula arising as multiple small vessels from the proximal left anterior descending artery (LAD) and draining into the pulmonary artery (PA). Initially, the patient was managed medically considering HCM as the cause of his symptoms but subsequently, with the findings of coronary artery fistula by CTA, the surgical correction of the fistula was advised. However, the patient opted for conservative treatment. At one year follow-up, he was well on optimal medical treatment with improvement in functional class from NYHA III to II. This describes a rare case of coronary artery to pulmonary artery fistula in a patient with hypertrophic cardiomyopathy that presented late in life.