A 63 year old man with ischaemic heart failure underwent orthotopic heart transplantation in 1999. During the first year following surgery, 12 routine endomyocardial biopsies were performed without apparent complication. Seven months after transplantation a continuous (systolic and diastolic) apical and left parasternal murmur was noted. Echocardiography showed no valvar lesions and the cause of the murmur remained unclear. Routine one year coronary angiography revealed a fistula between the distal left posterior descending artery and the left posterior vein. Based on the time of appearance of the murmur and the localisation of the fistula we postulated that the shunt was related to the endomyocardial biopsies.

Consequently we decided to close the fistula using a 3.5 mm (16 mm length) PTFE covered stent (Jostent Coronary Stent Graft, Jomed, Germany). Angiography after stenting confirmed a complete occlusion of the fistula. Following the procedure the murmur disappeared; there were no changes in the ECG and no increases in cardiac enzymes.

Left: baseline angiogram (anteroposterior cranial view) showing the fistula between the left posterior descending coronary artery and the left posterior descending vein. Right: angiogram (anteroposterior cranial view) after placement of the covered stent showing the complete closure of the fistula.