Late Internal Mammary Arteriovenous Fistula
A 51-year-old asymptomatic woman was found to have a continuous murmur at the left lower sternal edge and in the interscapular area. Eight years earlier, she had a Bentall’s operation for an aortic root aneurysm secondary to Marfan’s syndrome. The prosthetic aortic valve sounds were normal, with an ejection murmur across the valve. A transesophageal echocardiogram showed no intracardiac shunt and normal function of the aortic valve prosthesis. Subsequent cardiac catheterization and angiography showed a large left internal mammary artery with a fistulous connection into the adjacent internal mammary veins at the level of the diaphragm (Figure 1). The fistula was occluded with coil embolization (Figure 2), and the continuous murmur disappeared. The distal location of this fistula suggests that it may have resulted from damage caused by insertion of a chest drain at the time of aortic surgery.
The editor of Images in Cardiovascular Medicine is Hugh A. McAllister, Jr, MD, Chief, Department of Pathology, St Luke’s Episcopal Hospital and Texas Heart Institute, and Clinical Professor of Pathology, University of Texas Medical School and Baylor College of Medicine.
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