{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,8,27]],"date-time":"2025-08-27T14:40:18Z","timestamp":1756305618920,"version":"3.44.0"},"reference-count":24,"publisher":"BMJ","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["BMJ Case Reports"],"abstract":"<jats:p>A 56-year-old female patient was referred to our institution for atypical chest pain and palpitations. Physical examination, resting ECG and transthoracic echocardiogram were unremarkable. Stress perfusion scintigraphy was positive for anterior and apical myocardial ischaemia. A subsequent coronary angiogram showed no signs of atherosclerotic coronary artery disease; however, it revealed a coronary arteriovenous fistula and multiple other fistulous connections between the proximal segment of the left coronary artery and the pulmonary artery trunk. We present a rare case of a symptomatic coronary fistula that was percutaneously closed using an Amplatzer Vascular Plug, which resulted in clinical improvement and late fistula occlusion. This case report underlines the importance of thinking beyond atherosclerosis in the evaluation of chest pain syndromes. Moreover, it describes some of the angiogram caveats in assessing the coronary fistula number and morphology, as well as the cardiac-catheter potential for multiple pathway coronary artery fistulae closure.<\/jats:p>","DOI":"10.1136\/bcr-2013-009348","type":"journal-article","created":{"date-parts":[[2013,4,17]],"date-time":"2013-04-17T00:52:32Z","timestamp":1366159952000},"page":"bcr2013009348","source":"Crossref","is-referenced-by-count":0,"title":["Cardiovascular disease: thinking beyond atherosclerosis"],"prefix":"10.1136","volume":"2013","author":[{"given":"Luis Manuel","family":"Vilardouro Paiva","sequence":"first","affiliation":[{"name":"Department of Cardiology, Coimbra's Hospital Center and University, Coimbra, Portugal"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Marco","family":"Costa","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Coimbra's Hospital Center and University, Coimbra, Portugal"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Sergio","family":"Barra","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Coimbra's Hospital Center and University, Coimbra, Portugal"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Rui","family":"Providencia","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Coimbra's Hospital Center and University, Coimbra, Portugal"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"239","published-online":{"date-parts":[[2013,4,16]]},"reference":[{"key":"2025082707102744000_2013.apr16_1.bcr2013009348.1","doi-asserted-by":"crossref","first-page":"141","DOI":"10.3109\/13814780903329528","article-title":"Chest pain in primary care: epidemiology and pre-work-up probabilities","volume":"2013","author":"B\u00f6sner","year":"2009","journal-title":"Eur J Gen Pract"},{"key":"2025082707102744000_2013.apr16_1.bcr2013009348.2","doi-asserted-by":"crossref","first-page":"2360","DOI":"10.1001\/archinte.1984.00350220076018","article-title":"Arrhythmias in mitral valve prolapse. Effect of selection bias","volume":"2013","author":"Kramer","year":"1984","journal-title":"Arch Intern Med"},{"key":"2025082707102744000_2013.apr16_1.bcr2013009348.3","doi-asserted-by":"crossref","first-page":"270","DOI":"10.1016\/S0003-4975(99)01248-5","article-title":"Congenital Heart Surgery Nomenclature and Database Project: anomalies of the coronary arteries","volume":"2013","author":"Dodge-Khatami","year":"2000","journal-title":"Ann Thorac Surg"},{"key":"2025082707102744000_2013.apr16_1.bcr2013009348.4","first-page":"28","article-title":"Coronary artery anomalies in 126,595 patients undergoing coronary arteriography","volume":"2013","author":"Yamanaka","year":"1990","journal-title":"Catheter Cardiovasc Diagn"},{"key":"2025082707102744000_2013.apr16_1.bcr2013009348.5","unstructured":"Hoffman JI . Congenital anomalies of the coronary vessels and the aortic root. Heart disease in infants, children and adolescents. 5th edn. Baltimore: Williams and Wilkins, 1995:780."},{"key":"2025082707102744000_2013.apr16_1.bcr2013009348.6","doi-asserted-by":"crossref","first-page":"225","DOI":"10.1067\/mje.2000.102213","article-title":"Diagnosis of a left coronary artery to right ventricular fistula with progression to spontaneous closure","volume":"2013","author":"Cotton","year":"2000","journal-title":"J Am Soc Echocardiogr"},{"key":"2025082707102744000_2013.apr16_1.bcr2013009348.7","first-page":"e1","article-title":"ACC\/AHA 2008 guidelines for the management of adults with congenital heart disease: a report of the American College of Cardiology\/American Heart Association Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Adults with Congenital Heart Disease)","volume":"2013","author":"Warnes","year":"2008","journal-title":"J Am Coll Cardiol"},{"key":"2025082707102744000_2013.apr16_1.bcr2013009348.8","doi-asserted-by":"crossref","first-page":"190","DOI":"10.1016\/S0003-4975(00)01862-2","article-title":"Coronary artery fistulas: long-term results of surgical correction","volume":"2013","author":"Cheung","year":"2001","journal-title":"Ann Thorac Surg"},{"key":"2025082707102744000_2013.apr16_1.bcr2013009348.9","doi-asserted-by":"crossref","first-page":"849","DOI":"10.1161\/01.CIR.59.5.849","article-title":"Congenital coronary arteriovenous fistula. Report of 13 patients, review of the literature and delineation of management","volume":"2013","author":"Liberthson","year":"1979","journal-title":"Circulation"},{"key":"2025082707102744000_2013.apr16_1.bcr2013009348.10","doi-asserted-by":"crossref","first-page":"380","DOI":"10.1017\/S1047951104004056","article-title":"Review of an institutional experience of coronary arterial fistulas in childhood set in context of review of the literature","volume":"2013","author":"Holzer","year":"2004","journal-title":"Cardiol Young"},{"key":"2025082707102744000_2013.apr16_1.bcr2013009348.11","doi-asserted-by":"crossref","first-page":"415","DOI":"10.1007\/s00246-002-1334-6","article-title":"Coronary artery fistulas in neonates, infants, and children: clinical findings and outcome","volume":"2013","author":"Hsieh","year":"2002","journal-title":"Pediatr Cardiol"},{"key":"2025082707102744000_2013.apr16_1.bcr2013009348.12","doi-asserted-by":"crossref","first-page":"407","DOI":"10.1016\/S0002-9149(98)00878-9","article-title":"Prognostic significance of clinically silent coronary artery fistulas","volume":"2013","author":"Sherwood","year":"1999","journal-title":"Am J Cardiol"},{"key":"2025082707102744000_2013.apr16_1.bcr2013009348.13","doi-asserted-by":"crossref","first-page":"814","DOI":"10.1016\/j.jcin.2011.03.014","article-title":"Percutaneous closure of congenital coronary artery fistulae\u2014results and angiographic follow-up","volume":"2013","author":"Jama","year":"2011","journal-title":"JACC Cardiovasc Interv"},{"key":"2025082707102744000_2013.apr16_1.bcr2013009348.14","first-page":"110","article-title":"Coronary artery fistulas: how to manage them","volume":"2013","author":"Latson","year":"2007","journal-title":"Catheter Cardiovasc Interv"},{"key":"2025082707102744000_2013.apr16_1.bcr2013009348.15","first-page":"770","article-title":"Anomalous origin of the left main coronary artery from the right anterior aortic sinus: angiographic definition of anomalous course","volume":"2013","author":"Ishikawa","year":"1995","journal-title":"Am J Cardiol"},{"key":"2025082707102744000_2013.apr16_1.bcr2013009348.16","doi-asserted-by":"crossref","first-page":"261","DOI":"10.1007\/s10554-010-9718-9","article-title":"Complex coronary artery fistulas in adults: evaluation with multidetector computed tomography","volume":"2013","author":"Seon","year":"2010","journal-title":"Int J Cardiovasc Imaging"},{"key":"2025082707102744000_2013.apr16_1.bcr2013009348.17","doi-asserted-by":"crossref","first-page":"2823","DOI":"10.1161\/01.CIR.102.23.2823","article-title":"Noninvasive coronary angiography by retrospectively ECG-gated multislice spiral CT","volume":"2013","author":"Achenbach","year":"2000","journal-title":"Circulation"},{"key":"2025082707102744000_2013.apr16_1.bcr2013009348.18","doi-asserted-by":"crossref","first-page":"65","DOI":"10.1136\/thx.2.2.65","article-title":"Arteriovenous aneurysm on the pulmonary artery simulating patent ductus arteriosus botalli","volume":"2013","author":"Biorck","year":"1947","journal-title":"Thorax"},{"key":"2025082707102744000_2013.apr16_1.bcr2013009348.19","doi-asserted-by":"crossref","first-page":"877","DOI":"10.1148\/radiology.186.3.8094253","article-title":"Coronary-to-pulmonary artery shunts via the bronchial artery: analysis of cineangiographic studies","volume":"2013","author":"Matsunaga","year":"1993","journal-title":"Radiology"},{"key":"2025082707102744000_2013.apr16_1.bcr2013009348.20","doi-asserted-by":"crossref","first-page":"300","DOI":"10.1016\/S0003-4975(10)61563-9","article-title":"Surgical management of 56 patients with congenital coronary artery fistulas","volume":"2013","author":"Urrutia","year":"1983","journal-title":"Ann Thorac Surg"},{"key":"2025082707102744000_2013.apr16_1.bcr2013009348.21","doi-asserted-by":"crossref","first-page":"284","DOI":"10.1136\/hrt.49.3.284","article-title":"Transcatheter occlusion of coronary to bronchial anastomosis by detachable balloon combined with coronary angioplasty at same procedure","volume":"2013","author":"Reidy","year":"1983","journal-title":"Br Heart J"},{"key":"2025082707102744000_2013.apr16_1.bcr2013009348.22","doi-asserted-by":"crossref","first-page":"1026","DOI":"10.1016\/S0735-1097(02)01742-4","article-title":"Management of coronary artery fistulae. Patient selection and results of transcatheter closure","volume":"2013","author":"Armsby","year":"2002","journal-title":"J Am Coll Cardiol"},{"key":"2025082707102744000_2013.apr16_1.bcr2013009348.23","first-page":"E146","article-title":"Transcatheter closure of coronary artery fistula complicated by myocardial infarction","volume":"2013","author":"Kharouf","year":"2007","journal-title":"J Invasive Cardiol"},{"key":"2025082707102744000_2013.apr16_1.bcr2013009348.24","doi-asserted-by":"crossref","first-page":"299","DOI":"10.1111\/j.1540-8183.2001.tb00336.x","article-title":"Catheter closure of coronary artery fistulas","volume":"2013","author":"Qureshi","year":"2001","journal-title":"J Interv Cardiol"}],"container-title":["BMJ Case Reports"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/syndication.highwire.org\/content\/doi\/10.1136\/bcr-2013-009348","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,8,27]],"date-time":"2025-08-27T14:10:37Z","timestamp":1756303837000},"score":1,"resource":{"primary":{"URL":"https:\/\/casereports.bmj.com\/lookup\/doi\/10.1136\/bcr-2013-009348"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2013,4,16]]},"references-count":24,"alternative-id":["10.1136\/bcr-2013-009348"],"URL":"https:\/\/doi.org\/10.1136\/bcr-2013-009348","relation":{},"ISSN":["1757-790X"],"issn-type":[{"type":"electronic","value":"1757-790X"}],"subject":[],"published":{"date-parts":[[2013,4,16]]}}}