Images in Cardiovascular Medicine https://doi.org/10.4070/kcj.2016.0268 Print ISSN 1738-5520 • On-line ISSN 1738-5555

Korean Circulation Journal

Giant Right Coronary Artery with Coronary Artery Fistula Complicated by Infective Endocarditis: Multimodality Imaging Approach Dongjae Lee, MD, Mi-Hyang Jung, MD, Ho-Joong Youn, MD, Young Choi, MD, Jae Ho Byeon, MD, and Hae Ok Jung, MD Cardiovascular Center, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea

A 65-year-old woman presented to the emergency department feeling feverish and having dyspnea. A chest X-ray revealed multifocal nodular consolidation, indicating possible embolic infarction. Transthoracic echocardiography revealed vegetation attached to the aortic valve (Fig. 1A, arrow), resulting in moderate aortic regurgitation (see Supplementary Video 1, 2 in the onlineonly Data Supplement). Additionally, unusual flow originating from the right sinus of Valsalva was noted (Fig. 1B, asterisks and arrows, see Supplementary Video 3 in the online-only Data Supplement). The right ventricular (RV)-focused apical 4-chamber view revealed an oscillating echogenic mass attached to the RV inferoseptal wall (Fig. 1C, arrow). Color Doppler imaging revealed a turbulent flow draining to the RV from an uncertain dilated structure. The previously detected echogenic mass was found to be located at the point of fistulous drainage and considered vegetation (Fig. 1D: arrow head for fistula, asterisk for uncertain dilated structure, arrow for vegetation; Supplementary Video 4 in the online-only Data Supplement). A coronary computed tomographic angiography was immediately performed, revealing the presence of a giant right coronary artery (RCA, Fig. 1E) and combined coronary to RV fistula and vegetation (Fig. 1F: arrow heads for fistula, asterisk for giant RCA, arrow for vegetation). Final coronary angiography confirmed coronary to RV fistula, which originated from the distal RCA (Fig. 1G, arrowhead, see Supplementary Video 5 in the online-only Data Supplement). Surgery to remove the infected tissue and correct the

coronary fistula, along with a concomitant aortic valve replacement, was recommended. The operative findings (Fig. 1H) were generally consistent with the preoperative diagnosis. The patient recovered from postoperative care without further clinical deterioration. Our case emphasizes the need for multimodality imaging in patients having infective endocarditis combined with complex structural heart disease.

Supplementary Materials The online-only Data Supplements are available with article at https://doi.org/10.4070/kcj.2016.0268.

Received: July 21, 2016 / Revision Received: August 26, 2016 / Accepted: September 13, 2016 Correspondence: Mi-Hyang Jung, MD, Cardiovascular Center, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul 06591, Korea Tel: 82-2-2258-1128, Fax: 82-2-2258-1142, E-mail: [email protected] • The authors have no financial conflicts of interest. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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https://doi.org/10.4070/kcj.2016.0268

Giant Right Coronary Artery with Coronary Artery Fistula Complicated by Infective Endocarditis: Multimodality Imaging Approach.

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