• Images in cardiology

A 48 year old woman whose birth had been normal was administered to our hospital for examination of strong systolic heart murmur. She had been involved in a traffic accident three years previously, and a heart murmur had been detected since then.

Auscultation revealed a strong systolic murmur (Levine V/VI) with thrill at 3LSB. Transthoracic echocardiogram elucidated the shunt flow from left ventricle (LV) to right atrium (RA) associated with heart murmur. Transoesophageal echocardiogram revealed the shunt flow from LV to RA through the defect lying entirely on the RA side of the tricuspid valve during systolic phase (below). Cardiac catheterisation revealed O₂ step up at RA and left ventriculography demonstrated the shunt flow from LV to RA without ventricular septal defect (VSD) flow (right, upper panels). Qp/Qs calculated from Fick’s law was 2.0, which is considered indicative of surgical closure of the defect. At open heart surgery, a defect at the membranous portion between the LV and RA with an intact tricuspid valve was revealed (right, lowerpanels) and direct closure carried out. After the operation, the patient recovered uneventfully and has no residual heart murmur.

This case of an acquired LV to RA communication caused by non-penetrating chest trauma is very unusual. The acquired LV to RA communication is usually accompanied by tricuspid valve insufficiency along with ventricular septal defect (subparavalvar LV to RA fistula). However, there has been no previous report regarding an acquiredLV to RA communication with intact tricuspid valve (supravalvar LV to RA fistula). Therefore, this is the first report of supravalvar LV–RA fistula involved in non-penetrating cardiac injury.