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.