ABC | Volume 110, Nº4, April 2018

Image Simultaneous Dual Coronary Fistulas Ioannis Ntalas, 1 John B. Chambers, 1 Júlia Karády, 1,2 Ronak Rajani 1 Department of Cardiology - St Thomas’ Hospital - Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom 1 MTA-SE Cardiovascular Imaging Research Group - Heart and Vascular Center - Semmelweis University, Budapest, Hungary 2 Mailing Address: Ioannis Ntalas • Department of Cardiology, St Thomas' Hospital, Westminster Bridge, Lambeth, SE1 7EH, London, UK E-mail: Ioannis.Ntalas@gstt.nhs.uk , dr.ntalas@gmail.com Manuscript received May 29, 2017, revised manuscript July 06, 2017, accepted July 06, 2017 Keywords Systolic Murmurs; Echocardiography; Computed Tomography Angiography. DOI: 10.5935/abc.20180057 A 61-year-old man with type II diabetes mellitus was referred with breathlessness on exertion. On auscultation, there was a continuous ejection systolic murmur on the left upper sternal border. Transthoracic echocardiography showed a dilated vessel in aortic wall in the parasternal long axis view (Figure 1A) and a spherical lesion in the apical 4-chamber view (Figure 1B). A coronary computed tomographic angiographic (CTCA) study revealed a dilated and ectatic right coronary artery (RCA). It arose from the ascending aorta at the 12 o'clock position and followed a tortuous course around the right sided atrioventricular groove before passing into the basal inferoseptum draining into the base of the right ventricle. An additional fistulous connection could be detected between the posterior descending artery of the RCA and the left anterior descending artery (LAD-RCA fistula) (Figure 1G,H,I). After a normal dobutamine stress echocardiogram, a decision for continued medical therapy was taken. Primary coronary artery fistulas (CAF) are rare congenital communications between one or more coronary arteries and a cardiac chamber or a great vessel. The RCA represents the most frequent site of origin of CAF in 60% of cases followed by the left coronary artery in 35% while two CAF are uncommon (< 5%). The current case demonstrates the utility of CTCA in elucidating otherwise unusual transthoracic echocardiographic appearances. Author contributions Conception and design of the research and analysis and interpretationof thedata:Ntalas I, Chambers JB, Karády J, Rajani R; Acquisition of data: Ntalas I, Karády J, Rajani R; Writing of the manuscript: Ntalas I, Rajani R; Critical revision of the manuscript for intellectual content: Ntalas I, Chambers JB, Karády J, Rajani R. Potential Conflict of Interest No potential conflict of interest relevant to this article was reported. Sources of Funding There were no external funding sources for this study. Study Association This study is not associatedwith any thesis or dissertationwork. 397