A Case of Aorta-Right Atrial Tunnel Presented with an Asymptomatic Murmur
A 42-year-old female was transferred from private clinic with intermittent palpitation and cardiac murmur on July 2012. The patient had no specific medical history of illnesses such as hypertension or diabetes mellitus. There was no family history of aortic, collagen, vascular or congenital heart diseases. Vital signs were blood pressure of 109/64 mm Hg, pulse of 77 beats/min, respiration of 20 breaths/min, and body temperature of 36.5℃. Cardiac auscultation revealed continuous grade 3/6 murmur at the right 2nd and 3rd intercostal spaces. Heart size was normal according to the chest Xray and no apparent ST-segment and T-wave abnormalities were shown on the electrocardiography. The blood chemistries, including N-terminal pro-B natriuretic peptide, coagulation studies with fibrinogen, anti-nuclear antibody and complete blood cell counts, as well as cardiac enzymes and lipid profiles, were within normal limits. TTE and Doppler showed a tunnel-like structure with continuous Doppler signals from the left coronary sinus to the RA (). The pulmonary/systemic blood flow ratio was estimated at 1.3 : 1 measured by echocardiography. The left ventricle showed normal size and systolic function with an ejection fraction of 64%. Cardiac valves were also normal. Exercising treadmill tests showed negative finding. Although coronary angiography revealed the normal left coronary artery (LCA) (), there was a large tunnel-like structure beginning in the left coronary sinus, and terminating in the body of RA (). The tunnel showed aneurysmal dilatation, and the LCA arose separately from the tunnel (). Right coronary artery originates from right coronary cusp (). Cardiac-CT was performed in order to confirm the tunnel, and showed the tunnel taking its origin from the aortic root, passing posterior to the aortic root and entering the RA through a tortuous link (). Although we recommended a surgical treatment, the patient only wanted the surgery next year.