GRAPHIC REPORT

Heart Vessels (2004) 19:55–56 © Springer-Verlag 2004DOI 10.1007/s00380-003-0707-y

Yuichi Sato · Masayasu Mitsui · Hiroshi TakahashiTakuya Miyazawa · Hiroyuki Okabe · Fumio InoueJunji Kusama · Toshiyuki Horie · Naoya MatsumotoYoshitaka Hori · Satoru FuruhashiMotoichiro Takahashi · Katsuo Kanmatsuse

A giant left circumflex coronary artery – right atrium arteriovenous fistuladetected by multislice spiral computed tomography

Received: February 28, 2003 / Accepted: April 16, 2003

Key words Multislice spiral computed tomography · Coro-nary arteriovenous fistula

A 70-year-old man was referred to our hospital becauseof symptoms of congestive heart failure. The initialechocardiographic study revealed a dilated and poorly con-tractile left ventricle, a markedly dilated left circumflexcoronary artery (LCx), and an enormously dilated anoma-lous vessel inferior to the right atrium (RA). Color Dopplerflow mapping documented a turbulent flow in the LCx,draining into the RA through the anomalous vessel. AnLCx-RA arteriovenous fistula was suspected. Multislice spi-ral computed tomography (MSCT) imaging was performedusing a Somatom Volume Zoom (4-detector-row, Siemens,Stuttgart, Germany) with collimation 1.0mm, table feed1.5 mm/rotation, 140kV, 320mA, and gantry rotation time500ms. Our scan protocol and image reconstruction methodhave been reported previously.1 Metoprolol (40mg) wasgiven 90 min prior to the scan in order to reduce the heartrate to perform the single-phase algorithm.2–4 Followingdetermination of contrast transit time from the cubital veinto the ascending aorta by injecting 15 ml of nonionic con-trast medium (Iomeron 350100ml syringe, Eisai, Tokyo,Japan), the remaining contrast medium (85ml) was injectedat a speed of 3.0ml/s. Image reconstruction was made witha reconstruction window (250ms) positioned immediatelybefore the atrial contraction period, which could be recog-nized by the peak of the P wave on the monitor ECG. The

Y. Sato (*) · M. Mitsui · H. Takahashi · T. Miyazawa · H. Okabe ·F. Inoue · J. Kusama · T. Horie · N. MatsumotoDepartment of Cardiology, Nihon University Surugadai Hospital,1-8-13 Kanda-Surugadai, Chiyoda-ku, Tokyo 101-8309, JapanTel. �81-3-3293-1711; Fax �81-3-3295-1859e-mail: yuichisatoh@mac.com

Y. Hori · S. Furuhashi · M. Takahashi · K. KanmatsuseDepartment of Radiology, Nihon University Surugadai Hospital,Tokyo, Japan

reconstructed data were transferred to a computer worksta-tion (3D Virtuoso, Siemens) for postprocessing. The scanwas completed in 10min, and postprocessing for volumerendering and curved multiplanar reconstruction (MPR)images required 20min. Figure 1A–C demonstrate volume-rendering images of the right-anterior oblique, left-anterioroblique, and bottom views. A markedly dilated and tortu-ous LCx and an anomalous vessel with giant, multiple cysticstructures were documented. The drainage of the fistulainto the right atrium was clearly visualized by the curvedMPR image (Fig. 1D). The exercise myocardial perfusionsingle-photon emission computed tomography using a rest201Tl/stress 99mTc-tetrofosmin separate acquisition, dual-isotope protocol was normal. Cardiac catheterization re-vealed findings consistent with those obtained by MSCT,that is, the dilated and tortuous LCx with multiple dilationsof the fistula draining into the RA (Fig. 1E). Right heartcatheterization revealed a significant step-up of the oxygensaturation in the right atrium. The pulmonary to systemicblood flow ratio (Qp/Qs) was calculated to be 1.85. Thepatient underwent surgery in which the distal portion of theLCx and the site of the drainage were directly closed.

The recent development of imaging modalities suchas transthoracic or transesophageal echocardiography,electron-beam computed tomography, and magnetic reso-nance imaging has allowed direct visualization of coronaryartery anomalies.5–9 MSCT permits direct visualization ofthe whole coronary artery system with its high spatial reso-lution.1–4 In addition to volume-rendering images that en-able three-dimensional comprehension of the coronaryartery system, MPR analysis can specify the site of thedrainage in patients with a coronary arteriovenous fistula.Drawbacks of MSCT may include radiation exposure andpoor image reproducibility due to limited temporal resolu-tion (210–250ms). However, the latter can be overcome bythe use of �-blockers and appropriate reconstruction win-dow setting, as suggested by our retrospectively ECG-gatedimage reconstruction technique.1 MSCT may providedefinitive confirmation of the coronary arteriovenous fistulaand may become the diagnostic procedure of choice whenthis anomaly is suspected.

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References

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Fig. 1. Volume-renderingimages from the right-anterioroblique (A), left-anterioroblique (B), and bottom (C)views. A markedly dilated,tortuous left circumflex artery(LCx) and an enormouslydilated anomalous vessel areobserved. A curved multiplanarreconstruction (MPR) imageshows the site of drainage of theanomalous vessel into the rightatrium (D, arrow). E A selectiveangiogram of the LCx. Thedilated LCx, dilated anomalousvessel, and its site of drainageinto the right atrium (arrow) aredemonstrated. LAD, leftanterior descending artery;GCV, great cardiac vein; F,fistula; RA, right atrium; LMCA,left main coronary artery

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