Coronary artery fistula causing myocardial ischemia after heart transplantation

We present a case of symptomatic left anterior descending (LAD) artery to right ventricle fistula formation, following orthotopic heart transplant. Closure of the shunt with a covered stent in the LAD was a satisfactory initial management strategy, however long-term is limited by recurrent severe in-stent restenosis. The etiology, as well as the best long-term management strategy for this unusual complication is not well defined.