Efor Anjinasının Nadir Bir Nedeni: Sirkumfleks Arter-Sol Atriyal Apendiks Fistülü
Özet
Koroner arter fistülleri nadir görülmekle birlikte en sık sağ ventriküle drene olmaktadır. Klinik prezentasyon çoğunlukla efor dispnesi ile ortaya çıkar; buna ek olarak atipik göğüs ağrısı, çarpıntı ve yorgunluk eşlik edebilir. Tanı, koroner anjiyografide koroner arter ile fistülize olan yapı arasında direkt bağlantının ve anormal akımın gösterilmesi ile konulur. Bu amaçla altın standart yöntem invaziv koroner anjiyografi olmakla birlikte, non-invaziv alternatifler arasında koroner BT anjiyografi de yer almaktadır. Tedavi yaklaşımı; hastanın semptomlarına, fistülün boyutuna ve hemodinamik etkilerine göre belirlenir. Bu olguda, efor anjinası ve efor dispnesi şikayetleri ile başvuran hastada koroner BT anjiyografi sırasında sirkumfleks arterin sol atrial apendikse fistülize olduğu saptandı. Fistülün anatomik olarak küçük ve hemodinamik açıdan anlamlı olmaması nedeniyle medikal tedavi düzenlendi ve izlemde hastanın semptomlarında belirgin gerileme gözlendi.
Coronary artery fistulas are rare vascular anomalies characterized by abnormal connections bet- ween the coronary arteries and cardiac chambers or great vessels, accounting for a small propor- tion of all coronary anomalies. While the most common drainage site is the right ventricle, fistu- lization of the circumflex artery to the left atrial appendage represents an exceedingly rare vari- ant, with only a limited number of cases reported in the literature. We present a 58-year-old female patient who was admitted with exertional chest pain. Laboratory findings were unremarkable, transthoracic echocardiography revealed a preserved ejection fracti- on of 60% with no wall motion abnormality, and electrocardiography demonstrated sinus rhythm. Given her symptomatic presentation alongside a low calculated cardiovascular mortality risk, coronary computed tomography angiography (CTA) was performed. No obstructive coro- nary artery disease was identified; however, a fistulous connection from the circumflex artery to the left atrial appendage was incidentally detected. As the fistula was characterized as small, soli- tary, and hemodynamically insignificant, a conservative management strategy was adopted. Fol- lowing initiation of metoprolol therapy, a marked improvement in symptoms was observed at the one-month follow-up. This case highlights the importance of coronary CTA as a non-invasive diagnostic tool in the evaluation of rare structural coronary anomalies. It also demonstrates that medical therapy may achieve satisfactory symptomatic relief in hemodynamically insignificant fistulas. Nevertheless, long-term clinical and imaging-based surveillance remains essential even in conservatively ma- naged cases. This rare vascular anomaly should be considered in the differential diagnosis of pa- tients presenting with exertional angina and dyspnea
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