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An Asymptomatic Septal Perforator Coronary Artery–Left Ventricle Fistula Following Myectomy in a Patient With Obstructive Hypertrophic Cardiomyopathy

Hypertrophic cardiomyopathy, the most common inherited cardiac disease, constitutes a clinical challenge due to its heterogenous profile and its unpredictable natural progression. Surgical septal myectomy is considered a safe and effective treatment for relief of resistant heart failure symptoms related to outflow tract obstruction. We present a 47-year-old female patient with recent extensive successful septal myectomy due to obstructive hypertrophic cardiomyopathy, simultaneous mitral valvuloplasty with moderate residual regurgitation, and incidental existence of an asymptomatic left coronary artery fistula (LCAF) between the first septal perforator of the left anterior descending artery and the left ventricle (Figures 1 and 2). Especially, color Doppler revealed the exact myectomy site at the basal septum demonstrating a holodiastolic turbulent flow attributed to an iatrogenic coronary fistula connecting the septal perforator artery to the left ventricle, as demonstrated in Figure 3. Left coronary artery fistulas have sporadically been described as a complication of an extended septal myectomy due to surgical injury to intramyocardial vessels with a prevalence of 19% to 23% in 1 retrospective and prospective study, respectively. Coronary artery fistula consists an abnormal connection between coronary arteries and cardiac cavities or pulmonary vasculature. Coronary fistulas may be congenital draining in the right ventricle and further leading to congestive heart failure or acquired with limited hemodynamic significance due to low-pressure gradient between vessel and the left ventricle. Acquired LCAFs have been reported sporadically after extensive septal myectomy, mitral valve surgery, myocardial infarction, endomyocardial biopsy, coronary angioplasty,