Introduction: Coronary artery fistula (CAF) is a rare cardiac anomaly that typically presents as a continuous murmur in an otherwise asymptomatic patient. Occasionally, it can result in congestive heart failure or bacterial endocarditis. Objective: To better delineate the course of coronary artery fistula using an intracoronary injection of SonoVue contrast agent, whilst performing transthoracic echocardiography. Method and results: A referred 46-year-old male, with a history of exertional dyspnea for almost three months, was admitted to the hospital with progressive dyspnea, and assessed under suspicion of CAF. CAF was seen with a coronary angiogram, but the exact entry point in the left ventricle or left atrial wall could not be determined. CT angiography also failed to establish the drainage site , so CAG (coronary angiography) was repeated with the SonoVue contrast agent injected into LM (Left main) while using a Siemens echocardiography machine. Multiple views were obtained during the injection and revealed unusual flow in the left ventricle just below the PML (posterior mitral leaflet) and passing through the fistula to LV. Conclusion: Contrast-Enhanced Echocardiography by direct intracoronary injection of SonoVue contrast agent, is safe and can aid in the delineation of fistula drainage.

Introduction: Coronary artery fistula (CAF) is a rare cardiac anomaly that typically presents as a continuous murmur in an otherwise asymptomatic patient. Occasionally, it can result in congestive heart failure or bacterial endocarditis. Objective: To better delineate the course of coronary artery fistula for the first time, using the SonoVue contrast agent during transthoracic echocardiography. Method and results: A referred 46-year-old male with a known history of dyspnea on exertion for a period of almost three months was admitted to the hospital with progressive dyspnea, and assessed under suspicion of CAF. CAF, was seen with a coronary angiogram, but the exact entry point in the left ventricle or left atrial wall could not be determined. CT angiography also failed to establish the exact point of entrance to LV (left ventricle), so CAG (coronary angiography) was repeated with SonoVue contrast agent injected into LM (Left main) while using a Siemens echocardiography machine. Multiple views were obtained during the injection, and revealed unusual flow in the left ventricle just below the PML (posterior mitral leaflet) postero-lateral and passing through the fistula to LV. Conclusion: Contrast Enhanced Echocardiography is thought to be more sensitive and in affording an accurate delineation of CAF drainage into cardiac chambers, and can be utilized in a direct precise and safe way.

Background: On June 05, 2017, the U.S. Food and Drug Administration approved the Edwards Lifesciences SAPIEN S3 Valve for transcatheter mitral valve replacement of degenerated bioprosthetic mitral valves. We present a case of the youngest patient (13 years old) to undergo this procedure. Case presentation: At 10 years old, this female patient underwent bioprosthetic mitral valve replacement. Three years later, she began experiencing shortness of breath NYHA class III. A transthoracic echocardiography showed a degenerated bioprosthetic mitral valve and severe mitral stenosis with a mean pressure gradient of 18 mm Hg. After deeming the patient, a high risk for surgery, the heart team opted to perform a transcatheter mitral valve-in-valve replacement. After the valve delivery system crossed the degenerated valve, a SAPIEN valve balloon was slowly inflated without rapid pacing to allow for fine positioning. Transoesophageal echocardiography evaluation revealed a mean gradient of 5 mm Hg. The patient discharged after 2 days. At her 30-month follow-up, she reported regular daily activity with no shortness of breath, and a follow-up transthoracic echocardiography showed normal function of the right ventricle, which also had reduced in size. Her systolic pulmonary artery pressure decreased to 33 mm Hg, the mean pressure gradient of the left ventricular outflow tract was 10 mm Hg, and the mitral valve mean pressure gradient was 6 mm Hg. Case discussion: Transcatheter mitral valve replacement is feasible in young female patients with a small body surface area. Safety and long-term outcomes need more research in this age group.