Coronary artery fistula is a rare complication of endomyocardial biopsy, reported to occur in up to 8% of cardiac transplant recipients. The coronary angiogram shown in the Figure⇓ was obtained from a 67-year-old man 3 years after orthotopic heart transplantation, after a continuous systolic and diastolic murmur was noted on physical exam. Color-flow images from a transesophageal echocardiogram before cardiac catheterization suggested a coronary artery–to–right ventricle communication.
Hemodynamics at the time of cardiac catheterization were notable for an aortic pressure of 140 mm Hg systolic and 85 mm Hg diastolic, a left ventricular end-diastolic pressure of 9 mm Hg, a right ventricular pressure of 28 mm Hg systolic and 4 mm Hg diastolic, a pulmonary artery mean pressure of 17 mm Hg, and a pulmonary capillary wedge pressure of 8 mm Hg. The cardiac output, determined by the Fick method, was 5.3 L/min, with a cardiac index of 2.7 L · min−1 · m−2. The mixed venous O2 saturation was 72.4%, with a pulmonary artery O2 saturation of 70.1%. Blood sampled at the apex of the right ventricle had an O2 saturation of 86.2%.
Coronary angiography (Figure⇓, right) revealed marked left anterior descending coronary artery (LAD) dilatation in the proximal, middle, and distal portions, with a fistula (arrow) communicating between the distal LAD and the right ventricle. The diameter of the LAD is substantially greater than it was 1 year earlier (left), representing significant vascular remodeling secondary to increased blood flow through the artery.
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.
Circulation encourages readers to submit cardiovascular images to Dr Hugh A. McAllister, Jr, St Luke’s Episcopal Hospital and Texas Heart Institute, 6720 Bertner Ave, MC1-267, Houston, TX 77030.
- Copyright © 1997 by American Heart Association