case_images: PMC4247939_01
case_images: Echocardiography, continuous-wave spectral Doppler across the aortic valve showed severe aortic stenosis with mean gradient 70 mmHg and peak gradient 105 mmHg.
case_images: CRIC2014-213673.001.jpg
case_images: PMC4247939_01_CRIC2014-213673.001.jpg
case_images: fig1
case_images: Echocardiography showed global hypokinesia and severely reduced left ventricle systolic function with an ejection fraction of 25%, severe aortic stenosis (aortic valve area = 0.6 cm2, and mean gradient = 70 mmHg) pulmonary to systemic blood flow ratio Q p/Q s = 1.12 (Figure 1).
case_images: (a) Still-frame image of late filling of coronary angiogram to left system with selective engagment of the LAD showed LM fistula (black arrows) which join the fistuous vessel of the other coronary artery and then drainage to the right pulmonary artery (RPA). (b) Still-frame image of cornonary angiogram to left system with selective engagement of the LCX and LM fistula (black arrow) fistolous vessel fills from the LCX (red arrow). (c) Still-frame image of cornonary angiogram of the RCA shows the fistolous vessel fills from RCA. (d) The same injection with late filling shows the fistula drainge to RPA. LAD: left anterior descending. LCX: left cercumflex. LM: left main. RAC: right coronary artery. RPA:right pulmonary artery.
case_images: CRIC2014-213673.002.jpg
case_images: PMC4247939_01_CRIC2014-213673.002.jpg
case_images: fig2
case_images: CAF with a connection to a vascular structure cannot be clearly delineated (Figure 2), so computed tomography angiography (CTA) was undertaken for further anatomical clarification and better three-dimensional (3D) orientation. CTA confirmed the coronary AVM with multiple coronary artery fistulae connected to the right pulmonary artery (RPA) and left main (LM) fistula coursing between ascending aorta and the left atrium (LA), while the other fistula ran between the LA and a single left pulmonary vein (SLPV) (Figure 3).
case_images: (a) Volume rendering CTA showed LM fistula joining the fistulous vessel of the other coronary arteries draining into the RPA. (b) Curved MPR showed the insertion point of the fistula at RPA. LAD: left anterior descending artery. LPV: left pulmonary vein. LA: left atrium.
case_images: CRIC2014-213673.003.jpg
case_images: PMC4247939_01_CRIC2014-213673.003.jpg
case_images: fig3
case_images: CAF with a connection to a vascular structure cannot be clearly delineated (Figure 2), so computed tomography angiography (CTA) was undertaken for further anatomical clarification and better three-dimensional (3D) orientation. CTA confirmed the coronary AVM with multiple coronary artery fistulae connected to the right pulmonary artery (RPA) and left main (LM) fistula coursing between ascending aorta and the left atrium (LA), while the other fistula ran between the LA and a single left pulmonary vein (SLPV) (Figure 3).