Coronary Artery Fistula Draining into the Left Ventricle
A 48-year-old male presented with abdominal pain that had lasted for 2 months. He had no cardiovascular risk factor, and no cardiovascular symptom such as chest pain or dyspnea. He was diagnosed as gallbladder stone and admitted to our hospital for laparoscopic cholecystectomy. Preoperative electrocardiography was within normal limit, and chest X-ray showed no pathologic abnormality. He was consulted to cardiovascular department because surgeon heard a continuous cardiac murmur and ordered echocardiography for a preoperative evaluation. The echocardiography showed normal ejection fraction (64%). The mitral inflow E/A ratio was 1.63, and E/E' ratio was 12.0. The valvular morphology and function was normal. However, there was abnormal color flow within left ventricle predominantly during diastole (, ,, , ). It was originated from basal posterior wall and drained into the left ventricular cavity. The maximal velocity of blood flow draining into left ventricle was approximately 3.0 m/s. In short-axis great arterial view, left coronary artery appeared dilated. Multiple tortuous dilated vascular structures with internal blood flows disclosed by color Doppler image were also found around left ventricular myocardium. Especially, dilated large echo-free vascular structure was detected in the apical area. The connection between those dilated vascular structures and left coronary artery was suspected, but clear visualization of the connection was limited in 2-dimensional echocardiography. Coronary artery computed tomography (CT) scan was performed to confirm the pathologic anatomy of these abnormal findings. Coronary CT revealed markedly dilated (up to 16 mm) and serpentine whole left coronary arteries (). The left anterior descending artery was communicating with left circumflex artery at the apical posterior epicardium, and was directly connected to the basal posterior side of left ventricular cavity (). He was finally diagnosed as having CAF.\nSince the patient had no cardiovascular symptom, he underwent laparoscopic cholecystectomy without specific treatment of CAF. No clinical events occurred during his admission. The patient visited outpatient clinic a month after discharge without clinical events or symptoms.