CASE REPORT
A 46-year-old male was admitted to the hospital with progressive
dyspnea. He reported suffering from dyspnea upon exertion for 3 months
and had been referred from another hospital for further review due to
suspicion of coronary fistula, which was present on a coronary
angiogram. It had previously not been possible to determine the drainage
site. No abnormal findings had been observed using an initial chest
posterior-anterior view and electrocardiogram.
Investigations: Transthoracic and trans-esophageal
echocardiography revealed severe LV systolic dysfunction, moderate MR
(Mitral Regurgitation) (Figure 1), and with agitated saline small PFO
(patent foramen ovale) was observed with TEE (Trans-Esophageal
Echocardiography) between the LA (Left Atrium) and the RA (Right Atrium)
(Figure 2).
CT angiography was performed, but the results non informative about the
drainage site.
Therefore, a further coronary angiogram was performed (figure 3) using
the SonoVue contrast agent (injection of 1.0 ml SonoVue diluted with 9.0
ml normal saline, and injected into LM), at the same time as using a
Siemens echocardiography machine. Multiple views were obtained with the
injection and found flow in the left ventricle just below the PML
passing through fistula to LV (figures 4) and at the systolic phase with
MR to LA and through PFO to RA and RV.
Treatment: After heart team discussion and Given symptoms of
heart failure attributed to a hemodynamically significant shunt, the
decision was made to close it. The antegrade approach was used with
percutaneous closure with coils (figure 5). Immediately after closure,
the patient’s MR improved (figure 6).