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Coronary artery fistula

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A continuous murmur in a 10 month old boy with no medical history led to the diagnosis of a congenital coronary artery fistula between the left anterior descending coronary artery and the apex of the right ventricle. At 5 years old the child underwent unsuccessful surgical ligation of the fistula through a median sternotomy. Subsequent cross sectional and colour echocardiography showed a persistently dilated left anterior descending coronary artery (arrows) draining into the apex of the right ventricle, which was consistent with the findings on selective left coronary artery angiography. At 7 years old, percutaneous occlusion of the fistula was performed by an arterial approach under local anaesthesia. A soft detachable silicone balloon mounted on a 1.5 F catheter was placed in the distal part of the leftanterior descending coronary artery. Inflation with iso-osmotic contrast agent was realised leading to complete occlusion and no electrocardiographic changes. The balloon was then released from the catheter. Fourteen months later, colour echocardiography confirmed persistent occlusion of the fistula with no residual shunt. This case illustrates both echocardiographic and angiographic aspects of congenital coronary artery fistula. Moreover, it shows different therapeutic options in the closure of congenital coronary artery fistula with initial failed surgical ligation but subsequent successful percutaneous occlusion using a detachable balloon. (Ao, aorta; LAD, left anterior descending coronary artery; LV, left ventricle; RV, right ventricle.)