CASE REPORT
A 46-year-old male was admitted to hospital with progressive dyspnea. He
reported suffering from dyspnea upon exertion for 3 months and had been
referred from another hospital for further review due to suspicion of
coronary fistula, which was present on a coronary angiogram. It had
previously not been possible to determine the exact entrance point in
the left ventricle or the left atrial wall. No abnormal findings had
been observed using an initial chest posterior-anterior view and
electrocardiogram.
Investigations: Transthoracic and trans-esophageal
echocardiography revealed severe LV systolic dysfunction, moderate MR
(Mitral Regurge), and with agitated saline small PFO (patent foramen
ovale) was observed with TEE (Trans-Esophageal Echocardiography) between
the LA (Left Atrium) and the RA (Right Atrium).
CT angiography was performed, delineating the course of the fistula, but
did not provide detailed information about the site of drainage into the
cardiac chamber (figure 4).
Therefore, a further coronary angiogram was performed (figure 5) using
the SonoVue contrast agent (injection of 1.0 ml SonoVue diluted with 9.0
ml normal saline, and injected into LM), at the same time as using a
Siemens echocardiography machine. Multiple views were obtained with the
injection, and found unusual flow in the left ventricle just below the
PML postero-lateral and passing through fistula to LV (figures 1 and 3 )
and at the systolic phase with MR to LA and through PFO to RA and RV
(figure 2).
Treatment: After consultation with the heart team, the decision
was made to close it. The antegrade approach was used with percutaneous
closure with coils. Immediately after closure, the patient’s MR
improved.