A 20-year-old man with right bundle branch block in recordedECG was referred to our department. His physical examinationwas unremarkable. Transthoracic echocardiography showeda severe hypertrophy of the interventricular septum (22 mm)which contained multiple echo-free spaces of the vascularnature. A flow pattern suggestive to a coronary artery fistulainto the left ventricle was recorded. The patient was referredfor a coronary angiography, which revealed an arteriovenousmalformation starting from the septal branch of the enlarged leftanterior descending artery. The malformation communicatedwith the lumen of the left (arterial phase) and right ventricle(venous phase) as well. The posterior descending artery wasfed exclusively from the described arteriovenous malformation.99mTc MIBI SPECT images showed a moderately reversible perfusiondefect in the inferior wall, suggesting non-critical ischemiaof this region

Kostkiewicz, Magdalena

Suchon, Elzbieta

Szot, Wojciech

Nuclear Medicine Review

English

A 20-year-old man with right bundle branch block in recorded

ECG was referred to our department. His physical examination

was unremarkable. Transthoracic echocardiography showed

a severe hypertrophy of the interventricular septum (22 mm)

which contained multiple echo-free spaces of the vascular

nature. A flow pattern suggestive to a coronary artery fistula

into the left ventricle was recorded. The patient was referred

for a coronary angiography, which revealed an arteriovenous

malformation starting from the septal branch of the enlarged left

anterior descending artery. The malformation communicated

with the lumen of the left (arterial phase) and right ventricle

(venous phase) as well. The posterior descending artery was

fed exclusively from the described arteriovenous malformation.

99mTc MIBI SPECT images showed a moderately reversible perfusion defect in the inferior wall, suggesting non-critical ischemia

of this region

Jagiellonian Univeristy Repository

80Nuclear Medicine Review 2012, 15, 1: 80–8210.5603/NMR.2012.0014Copyright © 2012 Via MedicaISSN 1506–9680Case  reportAbstractA 20-year-old man with right bundle branch block in recorded ECG was referred to our department. His physical examination was unremarkable. Transthoracic echocardiography showed a severe hypertrophy of the interventricular septum (22 mm) which contained multiple echo-free spaces of the vascular nature. A flow pattern suggestive to a coronary artery fistula into the left ventricle was recorded. The patient was referred for a coronary angiography, which revealed an arteriovenous malformation starting from the septal branch of the enlarged left anterior descending artery. The malformation communicated with the lumen of the left (arterial phase) and right ventricle (venous phase) as well. The posterior descending artery was fed exclusively from the described arteriovenous malformation. 99mTc MIBI SPECT images showed a moderately reversible perfu-sion defect in the inferior wall, suggesting non-critical ischemia of this region. Key words: coronary artery fistula, transthoracic echocardiography, 99mTc MIBI SPECTNuclear Med Rev 2012; 15, 1: 80–82Left coronary arteriovenous malformation with fistulous connections to the left  and right ventriclesCorrespondence to: Magdalena Kostkiewicz MD, PhDNuclear Medicine Dept, John Paul II HospitalPradnicka 80 Str., 31–202 Krakow, PolandA 20-year-old man with RBBB on ECG was referred to our department. His physical exam was unremarkable. Transthoracic echocardiography (TTE) showed a severe hypertrophy of the in-terventricular septum (22 mm) which contained multiple echo-free spaces which were filled with color when using the Doppler method, indicating the vascular nature of the lesion (Figure 1). Moreover, a flow pattern suggestive of a coronary artery fistula into the left ventricle was recorded (Figure 2). Accordingly, the patient was referred for a coronary angiography, which revealed Elzbieta Suchon, Magdalena Kostkiewicz, Wojciech Szot Nuclear Medicine Dept, John Paul II Hospital, Krakow, Poland[Received 1 II 2012; Accepted 16 II 2012]Figure 1. Transthoracic echocardiography (long axis view) demon-strates a severe hypertrophy of interventricular septum with vascular structures seen in color Doppler (arrow)81www.nmr.viamedica.plElzbieta Suchon et al., Left coronary arteriovenous malformation with fistulous connections to the left and right ventriclesCase  reportan arteriovenous malformation starting from the septal branch of the enlarged left anterior descending artery (Figure 3). The malformation communicated with the lumen of the left (arterial phase) and right ventricle (venous phase) as well. The posterior descending artery (PDA) was fed exclusively from the described arteriovenous malformation. The treadmill protocol was clinically negative, but a horizontal ST segment depression of 1.5 mV developed in multiple ECG derivation. 99mTc MIBI SPECT images acquired 30 min after peak exercise and 60 min after rest injections demonstrated a mode-rately reversible perfusion defect in the inferior wall, suggesting non-critical ischemia of this region (Figures 4, 5).Figure 2. Transthoracic color-flow Doppler echocardiography (apical 4-chamber view) shows a fistula draining into the left ventricle (arrow)Figure 3. Coronary angiography demonstrates an arteriovenous mal-formation (arrow) starting from the septal branch of the enlarged left anterior descending arteryFigure 4. Comparison of myocardial perfusion in GSPECT study at rest and stress. Please note the extent of perfusion defect at stress in the area of infero-septal wall with lower grade extent to antero-septal wall (SRS: Summed Rest Score, SSS: Summed Stress Score)82Nuclear Medicine Review 2012, Vol. 15, No. 1www.nmr.viamedica.plCase  reportThe imaging data was crucial in deciding to keep the patient under observation despite favorable clinical data. Coronary artery fistulas vary widely in their morphological appearance and presentations. The majority of patients are asymptomatic but angina, myocardial infarction, heart failure and endocarditis have been reported [1, 2]. Therapeutic approaches for coronary artery fistula are gene-rally controversial. Options include percutaneous intracoils place-ment, surgical intervention or conservative treatment [1–4]. In our patient, the fistulae were small, asymptomatic and not suitable for percutaneous closure. We decide to treat the patient conserva-tively. The accompanying images underscore the importance of using different methods like TTE, SPECT and coronary angiog-raphy to most effectively diagnose patients with coronary artery malformations, as in this case.References1. Palloshi A, Aprigliano G. Myocardial ischemia due to a large coro-nary-pulmonary fistula with plexus-like morphology. J Cardiovasc Med (Hagerstown) 2008; 9: 1163–1165.2. Sato F, Koishizawa T. Stress/Rest (99m) Tc-MIBI SPECT and 123I –BMIPP scintigraphy for indication of surgery with coronary artery to pulmonary artery fistula. Int Heart J 2005; 46: 355–361.3. Cebi N, Schulze-Waltrup N, Frömke J, Scheffold T, Heuer H. Congenital coronary artery fistulas in adults: concomitant pathologies and treat-ment. Int J Cardiovasc Imaging 2008; 24: 349–355.4. Arslan S, Gurlertop Y, Elbey MA, Karakelleoglu S. Multiple coro-nary-cameral fistulae causing angina pectoris. Tex Heart Inst J 2009; 36: 622–623.Figure 5. Left ventricular function and perfusion in GSPECT study at rest and stress. Please note a slight improvement in left ventricular function at stress, possible a result of hyper contractility of anterior and latero-inferior wall

Left coronary arteriovenous malformation with fistulous connections to the left and right ventricles

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Left coronary arteriovenous malformation with fistulous connections to the left and right ventricles

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