Iatrogenic Left Ventricle-to-Coronary Venous Fistula
A 70-year-old man with a history of childhood rheumatic fever was referred to our hospital for surgical correction of aortic stenosis. Severe aortic stenosis was confirmed using preoperative transthoracic echocardiography, which showed a peak gradient across the aortic valve of 83 mm Hg with a calculated valve area of 0.7 cm2. The patient underwent coronary angiography at an outside facility and the study was submitted for review and second opinion regarding a possible “left ventricle-to-left anterior descending artery fistula.”
Contrast ventriculography in the right anterior oblique projection (Figure 1) demonstrated an angled pigtail catheter within the left ventricle in mid-diastole. The contrast agent opacified left the ventricular cavity and also the anterior cardiac vein. During systole (Figure 2), contrast agent was shown flowing from the pigtail side hole into the myocardium, with subsequent opacification of the anterior cardiac vein.
The cineangiogram of the power contrast injection (see Movie) showed the stable position of the entrapped pigtail catheter within the ventricle and the distortion of the intrinsic curvature of the catheter. Venous injection was confirmed by the late filling of the coronary sinus.
The pigtail catheter likely became entrapped in the papillary muscles on insertion into the left ventricle. This fixed the catheter in place with one of the side holes in close apposition to the endocardium. The subsequent power injection induced a fistulous tract between the side hole of the catheter and the anterior cardiac vein.
The online-only Data Supplement, which contains a movie, can be found at http://circ.ahajournals.org/cgi/content/full/114/3/e50/DC1.