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European Journal of Echocardiography Advance Access originally published online on August 27, 2008
European Journal of Echocardiography 2009 10(2):352; doi:10.1093/ejechocard/jen229
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Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2008. For permissions please email: journals.permissions@oxfordjournals.org.

Multiple coronary to left ventricular fistulae

Nalyaka Sambu1,*, Rajan Sharma2 and Paul R. Kalra3

1 Department of Cardiology, Portsmouth Hospitals NHS Trust, Castle Lane East, Bournemouth, Dorset BH7 7DW, UK
2 Department of Cardiology, Ealing Hospital NHS Trust, London, UK
3 Department of Cardiology, Portsmouth Hospitals NHS Trust, Portsmouth UK

Received 20 April 2008; accepted after revision 8 August 2008; online publish-ahead-of-print 27 August 2008.

* Corresponding author. Tel: +44 1202303626. E-mail address: sambunh{at}hotmail.com


  Abstract

A 39-year-old female admitted with chest pain, dyspnoea and abnormal electrocardiograph (anterior T wave inversion) was referred for cardiac investigation. Cardiac catheterization demonstrated separate origins of the left anterior descending and circumflex arteries with multiple fistulae passing directly into the left ventricular cavity. There was no evidence of atheromatous coronary disease. The right coronary artery was normal. Left ventricular function appeared preserved, but end diastolic pressure was elevated. In view of progressive symptoms, she underwent stress echocardiography. Baseline study showed normal left ventricular systolic function without wall motion abnormalities. At peak-dose dobutamine, there was dilatation of the left ventricular cavity with marked hypokinesis of the left ventricular apex, mid and apical inferoseptum and mid and apical anterior wall. The patient developed chest tightness at peak-dose dobutamine. Coronary artery fistula is an extremely rare presentation. Stress echocardiogram confirmed a marked inducible ischaemic response. The mechanism is likely to involve a ‘steal phenomenon’ with blood following a low-pressure route to the left ventricle with subsequent elevation in end diastolic pressure. The net result is inducible ischaemia. In this case, the patient was intolerant of all beta blockers due to asthma and calcium channel antagonists were found to be ineffective. Ivabradine resulted in symptomatic improvement.

Keywords: Coronary artery fistulae; Left ventricle; Inducible ischaemia; Dobutamine stress echocardiogram; Cardiac catheterization; Coronary angiography


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