Giant Aneurysm of Right Coronary Artery Fistula Into Left Ventricle Coexisting With Noncompaction of Left Ventricular Myocardium Bo Jiang, MD, Ya Yang, MD, Fang Li, MM, Ning Ma, MD, Shan Wu, MM, Rongjuan Li, MD, and Ruijuan Su, MD Department of Echocardiography and Department of Radiology, Beijing Anzhen Hospital, Capital Medical University, and Beijing Institute of Heart, Lung and Blood Vessel Disease, Beijing, China
Coronary artery fistula (CAF) and noncompaction of the ventricular myocardium (NCVM) result from obliteration or compact failure of the intramyocardial trabecular sinusoids to form a ventricular cavity wall. The draining site of a right coronary artery (RCA) fistula may usually be the right ventricle, right atrium, or pulmonary artery. An RCA aneurysm with a fistula to the left ventricle is rare. We report a patient with an RCA aneurysm with a fistula to the left ventricle coexisting with NCVM. The patient’s condition was diagnosed by echocardiography and contrastenhanced multidetector computed tomography. (Ann Thorac Surg 2014;98:e85–6) Ó 2014 by The Society of Thoracic Surgeons oronary artery fistula (CAF) drainage into the left ventricle coexisting with noncompaction of the ventricular myocardium (NVCM) is fairly rare. Both diseases result from obliteration or compact failure of the intramyocardial trabecular sinusoids to form a ventricular cavity wall. CAF murmurs vary from the fistula drainage site and the pressure gradient between the aorta and the cardiac chambers. Treatment by surgical closure or a transcatheter procedure gives the best result.
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A 59-year-old farmer was hospitalized at our cardiology department with symptoms of chest distress, angina, and fatigue. He was healthy and had no family history of any cardiac diseases. His condition was diagnosed as coronary artery disease at a local clinic. Electrocardiography showed left ventricle hypertrophy, blood pressure of 110/ 70 mm Hg, New York Heart Association grade III–IV heart failure, and a diastolic grade II–III murmur in the left fourth intercostal space. An admission chest radiogram showed pulmonary plethora with a faint, large shadow in the right lower lung field. Transthoracic echocardiography (TTE) showed an enlarged left ventricle of 82 mm in end-diastole and an ejection fraction of 33% calculated by a modified Simpson’s method. The right coronary artery diameter increased to 13 mm from the (right coronary) beginning (Figs 1A1, 1A2). Accepted for publication June 16, 2014. Address correspondence to Dr Yang, Department of Echocardiography, Beijing Anzhen Hospital, Capital Medical University and Beijing Institute of Heart, Lung and Blood Vessel Disease, Beijing, China, 100029; e-mail: [email protected].
Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier
During a short walk, it dilated to 60 53 mm, forming an artery aneurysm (AA) (Figs 1B1, 1B2) and then wriggled to a 25-mm diameter tube (Figs 1C1, 1C2); finally it was injected into the left ventricle through a 13-mm fistula (Figs 1D1, 1D2). TTE also revealed ample trabecular structures and an interweave-like honeycomb net in the apex and midcavity of the left ventricle. A color Doppler scan demonstrated flow in the intertrabecular recesses, suggesting the communication with ventricular cavity. In the short-axis view of the left ventricle, the ratio of noncompacted to compacted myocardial layers at the site of maximal wall thickness was 2 at end-diastole, and most noncompacted segments were hypokinetic (Figs 1E1, 1E2). Echocardiography suggested a giant RCA aneurysm with a fistula to the left ventricle coexisting with NCVM. The results of contrast-enhanced multidetector computed tomography (MDCT) were consistent with those of TTE. Volume rendering and curve planar reconstruction techniques showed how the right coronary artery dilated (Figs 2A–D). NCVM was clearly visible on multiplanar reconstruction images (Fig 2E).
Comment Coronary artery fistula (CAF) is an abnormal connection between a coronary artery and any of the 4 chambers of heart or any of the great vessels. CAF is present in 0.002% of the general population and represents 0.2% to 0.4% of all congenital cardiovascular diseases [1]. The prevalence of NCVM is
Coronary artery fistula (CAF) and noncompaction of the ventricular myocardium (NCVM) result from obliteration or compact failure of the intramyocardial trabecular sinusoids to form a ventricular cavity wall. The draining site of a right coronary artery (RCA) fistula may usually be the right ventricle, right atrium, or pulmonary artery. An RCA aneurysm with a fistula to the left ventricle is rare. We report a patient with an RCA aneurysm with a fistula to the left ventricle coexisting with NCVM. The patient’s condition was diagnosed by echocardiography and contrastenhanced multidetector computed tomography. (Ann Thorac Surg 2014;98:e85–6) Ó 2014 by The Society of Thoracic Surgeons oronary artery fistula (CAF) drainage into the left ventricle coexisting with noncompaction of the ventricular myocardium (NVCM) is fairly rare. Both diseases result from obliteration or compact failure of the intramyocardial trabecular sinusoids to form a ventricular cavity wall. CAF murmurs vary from the fistula drainage site and the pressure gradient between the aorta and the cardiac chambers. Treatment by surgical closure or a transcatheter procedure gives the best result.
C
A 59-year-old farmer was hospitalized at our cardiology department with symptoms of chest distress, angina, and fatigue. He was healthy and had no family history of any cardiac diseases. His condition was diagnosed as coronary artery disease at a local clinic. Electrocardiography showed left ventricle hypertrophy, blood pressure of 110/ 70 mm Hg, New York Heart Association grade III–IV heart failure, and a diastolic grade II–III murmur in the left fourth intercostal space. An admission chest radiogram showed pulmonary plethora with a faint, large shadow in the right lower lung field. Transthoracic echocardiography (TTE) showed an enlarged left ventricle of 82 mm in end-diastole and an ejection fraction of 33% calculated by a modified Simpson’s method. The right coronary artery diameter increased to 13 mm from the (right coronary) beginning (Figs 1A1, 1A2). Accepted for publication June 16, 2014. Address correspondence to Dr Yang, Department of Echocardiography, Beijing Anzhen Hospital, Capital Medical University and Beijing Institute of Heart, Lung and Blood Vessel Disease, Beijing, China, 100029; e-mail: [email protected].
Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier
During a short walk, it dilated to 60 53 mm, forming an artery aneurysm (AA) (Figs 1B1, 1B2) and then wriggled to a 25-mm diameter tube (Figs 1C1, 1C2); finally it was injected into the left ventricle through a 13-mm fistula (Figs 1D1, 1D2). TTE also revealed ample trabecular structures and an interweave-like honeycomb net in the apex and midcavity of the left ventricle. A color Doppler scan demonstrated flow in the intertrabecular recesses, suggesting the communication with ventricular cavity. In the short-axis view of the left ventricle, the ratio of noncompacted to compacted myocardial layers at the site of maximal wall thickness was 2 at end-diastole, and most noncompacted segments were hypokinetic (Figs 1E1, 1E2). Echocardiography suggested a giant RCA aneurysm with a fistula to the left ventricle coexisting with NCVM. The results of contrast-enhanced multidetector computed tomography (MDCT) were consistent with those of TTE. Volume rendering and curve planar reconstruction techniques showed how the right coronary artery dilated (Figs 2A–D). NCVM was clearly visible on multiplanar reconstruction images (Fig 2E).
Comment Coronary artery fistula (CAF) is an abnormal connection between a coronary artery and any of the 4 chambers of heart or any of the great vessels. CAF is present in 0.002% of the general population and represents 0.2% to 0.4% of all congenital cardiovascular diseases [1]. The prevalence of NCVM is
