231
Image focus
IMAGE FOCUS
doi:10.1093/ehjci/jeu205 Online publish-ahead-of-print 21 October 2014
.............................................................................................................................................................................
Right coronary artery –left ventricle fistula with giant coronary artery aneurysm Sarasa Isobe1, Daihiko Hakuno1†*, Susumu Isoda2, Katsumi Hayashi3, and Takeshi Adachi1 1 Department of Cardiology, National Defense Medical College, 3-2 Namiki, Tokorozawa, Saitama, Japan; 2Department of Cardiovascular Surgery, National Defense Medical College, Saitama, Japan; and 3Department of Radiology, National Defense Medical College, Saitama, Japan
* Corresponding author. Tel: +81 4 2995 1597; Fax: +81 4 2996 5200; Email: [email protected], [email protected] †
Present address: Department of Cardiovascular Medicine, Kyoto University Hospital, 54 Kawaharacho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan.
Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2014. For permissions please email: [email protected].
Downloaded from by guest on May 5, 2015
A 75-year-old woman was admitted to our hospital because of dyspnoea. She had been diagnosed as a right coronary artery –left ventricle (LV) fistula with a coronary artery aneurysm and moderate mitral regurgitation (MR) 5 years before. Surgical or transcatheter intervention was not considered at that time because she had no symptoms. Five months before the onset of dyspnoea, atrial fibrillation had been noted. On admission, coronary angiography and threedimensional coronary artery computed tomography showed a right coronary artery–LV fistula with a giant coronary artery aneurysm (diameter, 33 mm; Panels A and B). Transthoracic echocardiography revealed severe MR due to prolapse of the anterior mitral leaflet. An orifice of the fistula was located at the posterior wall of LV, just below the mitral annulus (arrows in Panel C), and the blood flow to the LV cavity was diastoledominant (arrow in Panel D) before the onset of atrial fibrillation. Giant right coronary artery aneurysm was also visualized (asterisks in Panel D). We speculated that the LV overload and left atrial enlargement was augmented by both MR and the shunt flow via the fistula, leading to the development of atrial fibrillation and acute decompensated heart failure. She was referred for surgical ligation of the fistula, resection of the coronary artery aneurysm and left atrial appendage, and mitral valvuloplasty. During surgery, the enlarged right coronary artery was easily identified (Panel E). Histological evaluation of the resected coronary aneurysm indicated cystic medial degeneration with mild atherosclerotic change. One year after cardiac surgery, she had no symptoms and myocardial perfusion scintigraphy did not show any ischaemic changes.
Image focus
IMAGE FOCUS
doi:10.1093/ehjci/jeu205 Online publish-ahead-of-print 21 October 2014
.............................................................................................................................................................................
Right coronary artery –left ventricle fistula with giant coronary artery aneurysm Sarasa Isobe1, Daihiko Hakuno1†*, Susumu Isoda2, Katsumi Hayashi3, and Takeshi Adachi1 1 Department of Cardiology, National Defense Medical College, 3-2 Namiki, Tokorozawa, Saitama, Japan; 2Department of Cardiovascular Surgery, National Defense Medical College, Saitama, Japan; and 3Department of Radiology, National Defense Medical College, Saitama, Japan
* Corresponding author. Tel: +81 4 2995 1597; Fax: +81 4 2996 5200; Email: [email protected], [email protected] †
Present address: Department of Cardiovascular Medicine, Kyoto University Hospital, 54 Kawaharacho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan.
Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2014. For permissions please email: [email protected].
Downloaded from by guest on May 5, 2015
A 75-year-old woman was admitted to our hospital because of dyspnoea. She had been diagnosed as a right coronary artery –left ventricle (LV) fistula with a coronary artery aneurysm and moderate mitral regurgitation (MR) 5 years before. Surgical or transcatheter intervention was not considered at that time because she had no symptoms. Five months before the onset of dyspnoea, atrial fibrillation had been noted. On admission, coronary angiography and threedimensional coronary artery computed tomography showed a right coronary artery–LV fistula with a giant coronary artery aneurysm (diameter, 33 mm; Panels A and B). Transthoracic echocardiography revealed severe MR due to prolapse of the anterior mitral leaflet. An orifice of the fistula was located at the posterior wall of LV, just below the mitral annulus (arrows in Panel C), and the blood flow to the LV cavity was diastoledominant (arrow in Panel D) before the onset of atrial fibrillation. Giant right coronary artery aneurysm was also visualized (asterisks in Panel D). We speculated that the LV overload and left atrial enlargement was augmented by both MR and the shunt flow via the fistula, leading to the development of atrial fibrillation and acute decompensated heart failure. She was referred for surgical ligation of the fistula, resection of the coronary artery aneurysm and left atrial appendage, and mitral valvuloplasty. During surgery, the enlarged right coronary artery was easily identified (Panel E). Histological evaluation of the resected coronary aneurysm indicated cystic medial degeneration with mild atherosclerotic change. One year after cardiac surgery, she had no symptoms and myocardial perfusion scintigraphy did not show any ischaemic changes.
