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1087
Pictorial .,.
Essay
:
Giant Fistula
Between
Left Ventricle: Oblique Chest Kan Takeda,1 Nakagawa
Yasuyuki
the Right Coronary
Diagnostic Radiograph Okuda,
Kaname
Artery and the of Right Posterior
Significance
Matsumura,
Hajime
Congenital coronary artery fistulas are uncommon. The prevalence of coronary artery fistulas in adults has been estimated as 0.13% [1]. Most of these fistulas communicate with the right atrium or ventricle or with the pulmonary artery; those emptying into the left atrium or ventricle are quite rare [2, 3]. Usually,
Sakuma,
Tomoyasu
Tagami,
and Tsuyoshi
patients with coronary artery fistula do not have clinical symptoms, and their chest radiographs do not show the corresponding shadow because the fistula is hemodynamically insignificant. When the fistula is large, however, chest radiographs show the secondary hemodynamic changes, such as cardiac enlargement
.
C Fig. 1.-37-year-old man with giant fistula between right coronary artery and left ventricle. A, Posteroanterior chest radiograph shows prominent right border of heart. B, Chest radiograph In right posterior oblique projection shows steep angle associated with double contour (arrow) on right border of heart. C, Right coronary arteriogram in left anterior oblique view verifies that angled proximal segment of dilated right coronary artery (straight arrow) triangular shadow shown In B. Curved arrow indicates site where fistula in right coronary artery empties into left ventricle.
Received March 9, 1992; accepted after revision May 1 , 1992. I All authors: Department of Radiology, Mie University School of Medicine, 2-1 74 Edobashi, AJR
159:1087-1090,
1992 0361-803X/92/i
595-1087
0 American
Roentgen
Ray Society
Tsu, Mie 51 4, Japan. Address reprint requests to K. Takeda.
causes
1088
TAKEDA
ET AL.
or increased pulmonary vasculature, depending on the emptying site. Moreover, the silhouette of the dilated tortuous vessel itself can be seen on the chest radiograph. We have examined four patients, each of whom had a giant fistula in the right coronary
Downloaded from www.ajronline.org by 113.86.163.46 on 10/06/15 from IP address 113.86.163.46. Copyright ARRS. For personal use only; all rights reserved
artery
emptying
into the left ventricle,
proved
by coronary
angiog-
raphy. In this essay, we illustrate the chest radiographs of these patients and describe the radiologic features that permit a specific diagnosis or suggest a coronary artery fistula.
We examined four patients, each of whom had a giant fistula between the right coronary artery and the left ventricle.
Fig. 2.-41-year-old
A, Posteroanterior
man with giant fistula
chest radiograph
in right coronary
shows prominence
artery
Fig. 3-45-year-old B, Right posterior C, Right coronary
man with giant
chest radiograph
fistula
graphs
artery of right tonguelike projection oblique view reveals
oblique radiograph shows arteriogram In left anterior
were
arteriognaphy
that empties
In middle of right border
in right coronary
shows mild protrusion
i992
All four patients were men between 37 and 45 years old (mean age, 41 years). The chief signs and symptoms were angina in two patients and fatigability in two patients; all had an end-diastolic murmur. Routine chest nadiognaphs were obtained in the standard four views: posteroanterior, lateral, left posterior oblique, and right posterior oblique. Cardiac catheterization and angiocandiography were done within a few days after the chest radio-
B, Right posterior oblique radiograph shows angle in upper part of right border C, Digital subtraction anglogram In left anterior oblique view shows markedly (arrow) was confirmed to be responsible for triangular shadow in B.
A, Posteroanterior
AJR:159, November
obtained. were
Into left ventricle. of heart. of heart, accompanied dilated and tortuous
Aortography
performed
in right
and selective
by double contour (arrow). right coronary artery. Angled
connecting with left ventricle. border of heart. (arrow) at lower end of right border of heart. abrupt bend in acute marginal segment (arrow),
coronary
and left anterior
which caused
proximal
shadow
oblique
segment
shown in B.
AJR:159, November
GIANT FISTULA
1992
views with biplane cineangiognaphy tnic, Milwaukee, WI). One patient subtraction angiognaphy.
Downloaded from www.ajronline.org by 113.86.163.46 on 10/06/15 from IP address 113.86.163.46. Copyright ARRS. For personal use only; all rights reserved
Chest
(Angiomax, General Elecwas examined with digital
Radiographs
Postenoantenior night
IN RIGHT CORONARY
border
chest
of the
had a smooth, the night upper
heart
radiognaphs in all but
revealed one
patient.
a prominent That
patient
flat right border of the heart. In another case, bonder of the heart looked angled (Fig. 1A). In
ARTERY
1089
this patient, a chest radiograph in the night posterior oblique view showed that the upper right bonder of the heart was prominent (Fig. 1 B). Right coronary arteriography in the left anterior oblique view revealed a markedly dilated right coronary artery; its proximal segment caused the prominence
seen on the right posterior oblique radiograph (Fig. 1C). A second patient had a prominence at the middle of the right
border
of the heart
shown
on a posteroantenior
chest
radiograph (Fig. 2A). In the right posterior oblique view, a shadow accompanied by a double contour was observed at
V
A
B Fig. 4.-42-year-old
A, Posteroanterior
man with giant fistula
In right coronary
C artery
communicating
with left ventricle.
chest radiograph shows flat right border of heart
B, Right posterior oblique radiograph, however, shows right border of heart as angled at lower end (arrows). C, Aortogram in left anterior oblique view reveals acute marginal segment of right coronary artery is angled (straight B. Curved arrow indicates anastomosis of flstula In right coronary artery with left ventricle.
:.
arrow),
.
Fig. 5.-57-year-old woman with pericardlal cyst A, Posteroanterior chest radiograph shows markedly protruded right border of heart. B, Right posterior oblique radiograph shows right border of heart (arrowheads) cleariy C, Contrast-enhanced CT scan shows cystic mass adjacent to right atrium (arrow).
in bulky shadow of pericardial
cyst
creating shadow shown In
1087
Pictorial .,.
Essay
:
Giant Fistula
Between
Left Ventricle: Oblique Chest Kan Takeda,1 Nakagawa
Yasuyuki
the Right Coronary
Diagnostic Radiograph Okuda,
Kaname
Artery and the of Right Posterior
Significance
Matsumura,
Hajime
Congenital coronary artery fistulas are uncommon. The prevalence of coronary artery fistulas in adults has been estimated as 0.13% [1]. Most of these fistulas communicate with the right atrium or ventricle or with the pulmonary artery; those emptying into the left atrium or ventricle are quite rare [2, 3]. Usually,
Sakuma,
Tomoyasu
Tagami,
and Tsuyoshi
patients with coronary artery fistula do not have clinical symptoms, and their chest radiographs do not show the corresponding shadow because the fistula is hemodynamically insignificant. When the fistula is large, however, chest radiographs show the secondary hemodynamic changes, such as cardiac enlargement
.
C Fig. 1.-37-year-old man with giant fistula between right coronary artery and left ventricle. A, Posteroanterior chest radiograph shows prominent right border of heart. B, Chest radiograph In right posterior oblique projection shows steep angle associated with double contour (arrow) on right border of heart. C, Right coronary arteriogram in left anterior oblique view verifies that angled proximal segment of dilated right coronary artery (straight arrow) triangular shadow shown In B. Curved arrow indicates site where fistula in right coronary artery empties into left ventricle.
Received March 9, 1992; accepted after revision May 1 , 1992. I All authors: Department of Radiology, Mie University School of Medicine, 2-1 74 Edobashi, AJR
159:1087-1090,
1992 0361-803X/92/i
595-1087
0 American
Roentgen
Ray Society
Tsu, Mie 51 4, Japan. Address reprint requests to K. Takeda.
causes
1088
TAKEDA
ET AL.
or increased pulmonary vasculature, depending on the emptying site. Moreover, the silhouette of the dilated tortuous vessel itself can be seen on the chest radiograph. We have examined four patients, each of whom had a giant fistula in the right coronary
Downloaded from www.ajronline.org by 113.86.163.46 on 10/06/15 from IP address 113.86.163.46. Copyright ARRS. For personal use only; all rights reserved
artery
emptying
into the left ventricle,
proved
by coronary
angiog-
raphy. In this essay, we illustrate the chest radiographs of these patients and describe the radiologic features that permit a specific diagnosis or suggest a coronary artery fistula.
We examined four patients, each of whom had a giant fistula between the right coronary artery and the left ventricle.
Fig. 2.-41-year-old
A, Posteroanterior
man with giant fistula
chest radiograph
in right coronary
shows prominence
artery
Fig. 3-45-year-old B, Right posterior C, Right coronary
man with giant
chest radiograph
fistula
graphs
artery of right tonguelike projection oblique view reveals
oblique radiograph shows arteriogram In left anterior
were
arteriognaphy
that empties
In middle of right border
in right coronary
shows mild protrusion
i992
All four patients were men between 37 and 45 years old (mean age, 41 years). The chief signs and symptoms were angina in two patients and fatigability in two patients; all had an end-diastolic murmur. Routine chest nadiognaphs were obtained in the standard four views: posteroanterior, lateral, left posterior oblique, and right posterior oblique. Cardiac catheterization and angiocandiography were done within a few days after the chest radio-
B, Right posterior oblique radiograph shows angle in upper part of right border C, Digital subtraction anglogram In left anterior oblique view shows markedly (arrow) was confirmed to be responsible for triangular shadow in B.
A, Posteroanterior
AJR:159, November
obtained. were
Into left ventricle. of heart. of heart, accompanied dilated and tortuous
Aortography
performed
in right
and selective
by double contour (arrow). right coronary artery. Angled
connecting with left ventricle. border of heart. (arrow) at lower end of right border of heart. abrupt bend in acute marginal segment (arrow),
coronary
and left anterior
which caused
proximal
shadow
oblique
segment
shown in B.
AJR:159, November
GIANT FISTULA
1992
views with biplane cineangiognaphy tnic, Milwaukee, WI). One patient subtraction angiognaphy.
Downloaded from www.ajronline.org by 113.86.163.46 on 10/06/15 from IP address 113.86.163.46. Copyright ARRS. For personal use only; all rights reserved
Chest
(Angiomax, General Elecwas examined with digital
Radiographs
Postenoantenior night
IN RIGHT CORONARY
border
chest
of the
had a smooth, the night upper
heart
radiognaphs in all but
revealed one
patient.
a prominent That
patient
flat right border of the heart. In another case, bonder of the heart looked angled (Fig. 1A). In
ARTERY
1089
this patient, a chest radiograph in the night posterior oblique view showed that the upper right bonder of the heart was prominent (Fig. 1 B). Right coronary arteriography in the left anterior oblique view revealed a markedly dilated right coronary artery; its proximal segment caused the prominence
seen on the right posterior oblique radiograph (Fig. 1C). A second patient had a prominence at the middle of the right
border
of the heart
shown
on a posteroantenior
chest
radiograph (Fig. 2A). In the right posterior oblique view, a shadow accompanied by a double contour was observed at
V
A
B Fig. 4.-42-year-old
A, Posteroanterior
man with giant fistula
In right coronary
C artery
communicating
with left ventricle.
chest radiograph shows flat right border of heart
B, Right posterior oblique radiograph, however, shows right border of heart as angled at lower end (arrows). C, Aortogram in left anterior oblique view reveals acute marginal segment of right coronary artery is angled (straight B. Curved arrow indicates anastomosis of flstula In right coronary artery with left ventricle.
:.
arrow),
.
Fig. 5.-57-year-old woman with pericardlal cyst A, Posteroanterior chest radiograph shows markedly protruded right border of heart. B, Right posterior oblique radiograph shows right border of heart (arrowheads) cleariy C, Contrast-enhanced CT scan shows cystic mass adjacent to right atrium (arrow).
in bulky shadow of pericardial
cyst
creating shadow shown In
