Voluminous fistula between the right coronary artery and a branch of the pulmonary artery causing myocardial ischemia

A 76-year-old female patient was referred to our institution because of typical chest pain. A continuous murmur was audible at the lower sternal border. A transthoracic echocardiogram showed non-dilated right and left ventricles with mild left ventricular inferior wall hypokinesia and an exercise stress test was positive for myocardial ischemia. A coronary angiogram showed no signs of atherosclerotic coronary artery disease, but it revealed a voluminous fistula between the proximal segment of the right coronary artery and a branch of the pulmonary artery, which was percutaneously closed using 3 embolization coils. Such late presentation of a voluminous coronary fistula is extremely rare and, to the best of our knowledge, very few case reports like this have been published.