Coronary artery fistula bypassed the left main coronary artery blocked by a large cardiogenic thrombus

A 68-year-old male who experienced recurrent chest pain for 2 days before being admitted to our hospital had a history of atrial fibrillation without taking anticoagulants. An electrocardiograph in the Chest Pain Centre showed atrial fibrillation. Troponin T increased 100-fold. Emergency coronary angiography showed the left main coronary artery (LMCA) blocked by a large thrombus (Panels A–C) (see Supplementary material online, Video S1) and the coronary artery fistula (CAF) originating from the right coronary sinus connected to the branch of interventricular septum bypassing the LMCA (Panels A–D). The patient received antithrombotic therapy (aspirin+ clopidogrel + low molecular weight heparin) for 1 week and underwent coronary angiography, which showed that the large thrombus in the LMCA was completely eliminated (Panels E and F) (Supplementary material online, Video S2). The intravascular ultrasound (IVUS) scan showed that only a little plaque was formed in the LMCA, the intima of the vessel was intact, and no plaque rupture was found (Panels G and H) (Supplementary material online, Video S3). The presence of the large thrombus in the LMCA was confirmed by atrial fibrillation based on its regular shape, and it was completely eliminated from sight after receiving antithrombotic therapy, and no abnormality was found in the IVUS.