• Images in cardiology

The patient is a 46 year old man with hypertension who on routine physical exam was noted to have a continuous cardiac murmur. Transthoracic echocardiogram demonstrated a sinus of Valsalva fistula extending into the right atrium. A transoesophageal echocardiogram (TOE) was then performed to better characterise the abnormality (see panels). The patient underwent closure of the aorto-right atrial fistula with a pericardial patch. The patient had an uneventful postoperative course and was discharged home. Aortic cusp fistulas should be part of the differential diagnosis when a continuous cardiac murmur is auscultated.

TOE short axis view at the level of the aortic valve. A defect (arrowhead) is visualised between the non-coronary cusp and the right atrium. LCC, left coronary cusp; NCC, non-coronary cusp; RA, right atrium; RCC, right coronary cusp; RV, right ventricle.

Colour Doppler of TOE short axis view at the level of the aortic valve. Blood flow can be seen passing from the non-coronary cusp into the right atrium.

Continuous wave Doppler of TOE short axis view at the level of the aortic valve. A high velocity flow through the fistula is evident in both systole and diastole.