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A 47 year old man with corrected tetralogy of Fallot was admitted with clinical heart failure. After prior left sided Blalock anastomosis at the age of 4 years, complete correction was performed at 9 years of age. Before pulmonary homograft insertion at 40, a fistula between the right coronary artery (RCA) and right ventricular outflow tract (RVOT) was detected. The procedure, which involved incision of the RVOT, was complicated by laceration of a small arterial branch, requiring end-to-end anastomosis.
Cardiac catheterisation confirmed the previously described fistula; however, selective intubation of an anomalous left sided coronary artery ostium failed.
At a pacemaker controlled rate of 60 beats/min, ECG gated multislice spiral computed tomography (MSCT) angiography (Somatom VolumeZoom, Siemens, Germany) was performed, during a 42 second breath hold. The volume rendered MSCT angiogram reveals an anomalous coronary artery that originates between the left and non-coronary sinus of Valsalva and trifurcates into a marginal, septal, and circumflex branch (upper panel).
A large calibre vessel, with branches to the right ventricle (RV), originates from an otherwise normal RCA, and terminates at the RVOT (lower panel, A and B), confirmed from inside the RVOT by virtual angioscopy (lower panel, C). A small, previously lacerated arterial branch runs across the RVOT to the anterior interventricular groove (B). The absence of a substantial anterior interventricular branch, and the location of the fistula at the RVOT, suggest that the fistula may have been formed after laceration of an anomalous LAD during surgical correction of tetralogy of Fallot, causing akinesia of the anterior wall.