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The identification of cardiac mass is one of the most important uses of two dimensional transthoracic and transoesophageal echocardiography. However, not all echogenic structures in the heart are pathologic. Erroneous diagnosis can lead to serious mismanagement, and overlooking a potentially lethal condition can be disastrous. The transthoracic apical four chamber view below (left panel) illustrates one such situation. The transthoracic echocardiogram shows a mass in the right atrium simulating a right atrial tumour or a thrombus. This echocardiogram, however, was obtained from a 9 year old boy who had undergone coil closure of a coronary artery fistula a few weeks previously. The patient was evaluated for a continuous murmur over the precordium and was found to have a coronary artery fistula by echocardiography and coronary angiography. Two dimensional echocardiography revealed dilatation of the left main coronary artery and left circumflex artery, which could be traced to a bulbous structure opening to the right atrium. Colour Doppler echocardiography showed a continuous turbulent flow at the site of entry of the fistula to the right atrium. A coronary angiogram showed a coronary arterial fistula from the left circumflex draining to the right atrium (centre panel). The fistula was closed with a 0.038 inch coil delivered through the arterial route. The right hand panel shows the coil occluding the site of entry of the fistula into the right atrium. The mass lesion seen in the right atrium (left panel) represents the clot formed within the bulbous end of the fistula a few days after the deployment of the coil. Percutaneous transcatheter embolisation is an effective treatment for coronary artery fistula. The coils facilitate thrombosis at the site of occlusion. In isolation the echocardiogram appears to indicate a dangerous condition, but with the necessary clinical background the diagnosis is obvious. With the increasing use of interventional procedures one needs to be aware of such possible misinterpretations in order to avoid erroneous diagnosis and serious patient mismanagement. A proper clinical evaluation of the patient is necessary before any imaging modality is undertaken.
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