Images in Cardiothoracic Medicine and Surgery

Left circumflex coronary artery fistula draining to left ventricle

Asian Cardiovascular & Thoracic Annals 2016, Vol. 24(1) 113–114 ß The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492314542287 aan.sagepub.com

Anuj Thakral1,2 and Jugal Sharma3

Figure 1. Transthoracic echocardiography. (a, b) Parasternal short-axis view showing the dilated left coronary sinus with the origin and proximal course of the fistula (arrow). (c, d) Parasternal long-axis view showing the coronary artery fistula (arrow) draining into the left ventricle.

Transthoracic echocardiography in a 6-year-old boy with palpitations showed a dilated left ventricle (LV) with end-diastolic and end-systolic dimensions of 53 and 38 mm, respectively, an ejection fraction of 54%, and a dilated left coronary sinus with a fistulous communication between the left coronary artery and the LV (Figure 1, Videos 1 and 2). Computed tomography angiography revealed dilatation of the left sinus of Valsalva, left main coronary artery, and entire course of the circumflex artery (Figure 2). The dilated left

1 Department of Radiology, Max Superspeciality Hospital, New Delhi, India 2 Department of Radiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India 3 Department of Cardiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India

Corresponding author: Jugal Sharma, MD, Department of Cardiology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Rai Barielly Road, Lucknow, Uttar Pradesh 226014, India. Email: [email protected]

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Asian Cardiovascular & Thoracic Annals 24(1)

Figure 2. Computed tomography angiography. (a) Panoramic view showing the entire course of the fistula from the left sinus of Valsalva to the left ventricular cavity. (b) Parasagittal projection showing transmural extension of the left circumflex into the left ventricular cavity. (c) Three-dimensional volume-rendered image depicting the entire course of the fistula (arrow).

The cardiac index calculated by the Fick method was 3.03 mLmin 1m 2 and the aorta-to-LV shunt was 3.97 mLmin 1 with a severe regurgitant fraction of 0.62. There was no step-up in oxygen saturation on oximetry of the right-sided chambers, confirming the absence of a left-to-right shunt. A large aorta-to-LV tunnel was seen arising from the left coronary sinus, giving rise to a normal left anterior descending artery and an aneurysmal left circumflex draining into the basal portion of the LV (Figure 3, Video 3). The left coronary artery could not be selectively hooked and device closure was not possible. The fistula was ligated surgically on cardiopulmonary bypass via a median sternotomy. On follow-up, there was improvement in symptoms and echocardiographic LV dimensions, with an ejection fraction of 65%. Figure 3. Diagnostic catheter angiography using a 5 F pigtail catheter (left anterior oblique view), showing a giant coronary artery fistula originating from the left coronary sinus, involving the left circumflex and draining into the left ventricle.

Funding This research received no specific grant from any funding agency in the public, commerical, or not-for-profit sectors.

Conflict of interest statement None declared.

circumflex extended through the posterosuperior wall of the LV into the ventricular lumen. LV catheter angiography revealed a dilated LV with normal function.

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Left circumflex coronary artery fistula draining to left ventricle.

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