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Coronary artery fistulas (CAFs) are rare coronary anomalies, most often detected incidentally. Although frequently asymptomatic, complex fistulas may lead to myocardial ischaemia, heart failure, or other complications, and optimal management remains controversial.

A 68-year-old patient presented with exertional dyspnoea and dizziness. Coronary angiography revealed intermediate left anterior descending artery stenosis with negative fractional flow reserve and a large CAF. Multislice computed tomography demonstrated complex bilateral CAFs originating from both coronary arteries, with drainage into the superior vena cava, right atrium, and descending aorta. Cardiac magnetic resonance imaging showed preserved myocardial tissue characteristics without ischaemia or fibrosis. Following Heart Team discussion, conservative management with optimal medical therapy was chosen. At 2-year follow-up, the patient remained asymptomatic without adverse events.

This case illustrates an exceptionally rare presentation of bilateral CAFs with multiple atypical drainage sites. It highlights the value of multimodality imaging for comprehensive anatomical and functional assessment and supports individualized, Heart Team-guided management in the absence of clear guideline recommendations.