Bilateral coronary-pulmonary artery fistulas presenting with new-onset heart failure and pulmonary hypertension.

UNLABELLED: Coronary artery fistulas are rare abnormalities that may lead to significant hemodynamic consequences, including heart failure and pulmonary hypertension. A healthy 58-year-old male presented with one month of moderate dyspnea, chest pain, and palpitations. Echocardiography showed severe eccentric left ventricular hypertrophy and reduced ejection fraction of 22%. Left and right heart catheterization revealed large tortuous vessels arising from the left anterior descending and right coronary arteries, both draining into the pulmonary artery, as well as elevated pulmonary capillary wedge pressure. Coronary computed tomography confirmed bilateral coronary-to-pulmonary artery fistulas. The patient underwent successful surgical closure of the fistulas and pulmonary artery reconstruction. At four-month follow-up, left ventricular ejection fraction had improved to 33%, and pulmonary hypertension probability was low. In conclusion, bilateral coronary-to-pulmonary artery fistulas are rare and can present with heart failure symptoms in adulthood. Surgical management remains a definitive treatment when percutaneous options are high risk. LEARNING OBJECTIVE: To recognize bilateral coronary-pulmonary artery fistulas as a rare cause of heart failure with variable presentation. To understand the importance of multimodality imaging (echocardiography, coronary angiography, and computed coronary tomography) in defining anatomy and hemodynamic significance. To discuss management strategies, emphasizing surgical closure as a safe option in complex anatomies. To highlight the need for early diagnosis and timely intervention to prevent ventricular remodeling, preserve cardiac function, and improve long-term outcomes.