Right Coronary Artery to Left Ventricular Fistula Associated with Infective Endocarditis of the Mitral Valve
A 27-year-old man was referred to our hospital due to mitral valve repair for severe mitral insufficiency secondary to Streptococcus viridians infective endocarditis which was diagnosed 2 months ago. He had been treated with intravenous antibiotics for 6 weeks before the referral.\nThe patient was in New York Heart Association Class II. On examination, he had tachycardia of 120 beats/minute and blood pressure of 110/70 mm Hg. He also had a grade 5/6 systolic murmur in the apex. The other findings were normal. Chest radiograph showed a cardiothoracic ratio of 60%. Laboratory investigations revealed mild anemia (hemoglobin level, 10.4 g/dL) and the erythrocyte sedimentation rate of 34 mm/h.\nA standard two-dimensional Doppler echocardiography was performed using Acuson Sequia™ C256 (Siemens, PA, USA), which showed dilation of the left ventricle (left ventricular dimension in enddiastole/end-systole: 62/43 mm) and left atrium (left atrial diameter: 43 mm). It also revealed an echo free space beneath the posterior mitral annulus and aneurysmal dilatation of the proximal right coronary artery in the parasternal long axis view of the left ventricular inflow tract (). The large mid and distal right coronary artery with a tortuous course, a defect in the posterior mitral leaflet, and the site of drainage of the fistulous tract into the left ventricle were visualized in parasternal short axis view, respectively (). Color-Doppler examination showed high velocity turbulent flow striking the posterior mitral leaflet, and mitral regurgitant flow directing anteriorly into the left atrium through the defect of the posterior mitral leaflet, during isovolumetric ventricular contraction and diastole (). However, the major mitral regurgitant flow was found to occur during systole. Coronary angiography () confirmed the presence of dilated and tortuous right coronary arteriovenous fistula drainage into the left ventricle. During the operation, the patient was found to have dilated and tortuous right coronary artery with a fistula tract of approximately 0.8 cm arising from the distal to posterior descending artery origin and opening into the left ventricle immediately inferior to the posterior mitral annulus. The defect (0.6 cm diameter) in the posterior leaflet was seen between the middle and medial scallops. No vegetation of fibrinoid materials was seen on the posterior leaflet surrounding the terminal portion of the fistula. The defect in the posterior leaflet was closed with a woven Dacron patch, and the fistula was sutured and closed inside the dilated distal right coronary artery. The patient's postoperative course was unremarkable. He was discharged on the tenth postoperative day.