Introduction: Coronary-cameral fistulae (CCF) are infrequent anomalies which are in general incidentally found during diagnostic coronary angiography. The iatrogenic fistulas are secondary to non-surgical interventions (endomyocardial biopsy (EMB), permanent pacing and ICD leads) or cardiac surgical procedures. (1, 2) Cardiac transplantation is an effective therapy for end-stage heart failure, with allograft rejection as a common problem after transplant. Thus, EMBs still remain the gold standard for its surveillance.

Case report: We present a case of a 43-years-old-male patient with dilatative cardiomyopathy who underwent an orthotropic, highly urgent heart transplantation in January 2012. The postprocedural recovery was complicated by a massive tricuspid regurgitation that required a tricuspid valve repair. The rest of the first year was uneventful, and the patient underwent 8 regular EMBs, which revealed no signs of cardiac allograft rejection. On a routine follow up angiogram one year after the heart transplantation a CCF between the right coronary artery and right ventricle was detected. Right-sided pressures were normal and there was no significant step-up in blood oxygen saturations from the right atrium to the right ventricle or pulmonary artery, so a conservative approach was chosen. Three years later the patient remains asymptomatic, with normal right sided pressures and cardiac output.

Conclusion: We hypothesize that the fistula in this patient developed during one of these EMBs. Prevalence of a CCFs is more common in the transplant population compared with the general population (5%–8% vs 0.2%) due to repetitive EMB. Like in this case, CCFs are mostly asymptomatic, with a tendency to spontaneously resolve and have a benign clinical outcome, and only seldom require intervention.