Endocarditis and coronary artery fistula: a case report

Abstract

Introduction: Coronary artery fistulae are rare abnormal congenital communications between a coronary artery and a cardiac chamber or great vessel. The majority of adult patients are asymptomatic, and it is most commonly discovered incidentally on coronary angiography.

Case presentation: We present the case of a 50-year-old woman, with a known fistula connecting the right coronary artery (RCA) and right atrium (RA), presenting with aortic valve endocarditis and pulmonary emboli. We detail the presentation and echocardiographic findings of aortic valve endocarditis with extension of the vegetation into the RA via the giant RCA fistula. We describe the clinical course including initial therapy, embolization of the right atrial vegetation to the lungs, and ultimately successful surgical correction after prolonged antibiotic therapy.

Discussion: Patients with coronary artery fistulae are susceptible to potentially serious complications including myocardial ischaemia, shunting and in this case infective endocarditis. We review the literature and discuss timings for corrective intervention.

Keywords: Cardiac computerized tomography; Case report; Coronary artery fistula; Echocardiography; Endocarditis.

Figure 1

Original echocardiography pictures from 2013 detailing the dilated vessel arising from the right coronary cusp with consequential turbulent colour flow in the right atrium. (A) Parasternal long axis two-dimensional view of the dilated vessel (red arrow). (B) Apical four chamber illustrating abnormal colour flow in the right atrium (red arrow). (C) Parasternal short axis demonstrating the dilated vessel (star) with colour flow in the vessel (red arrow) and into the right atrium (blue arrow). Ao, aorta; LA, left atrium; LV, left ventricle; RV, right ventricle.

Figure 2

(A) Computerised tomography demonstrating the giant right coronary artery (red arrow). (B) Three-dimensional reconstruction displaying the size and tortuosity of the vessel.

Figure 3

Echocardiography demonstrating aortic valve endocarditis, aortic incompetence and vegetation protruding into the right atrium. (A) Parasternal long axis view of the aortic valve masses. (B) Angulated parasternal view of the right ventricular inflow illustrating the right coronary fistula (red arrow) and vegetation into the right atrium (blue arrow). (C) Apical four chamber view with tip of the vegetation seen in the right atrium (red arrow). (D) Transoesophageal echocardiogram highlighting the abnormal aortic valve, aortic regurgitation, and giant right coronary artery (red arrow). Ao, aorta; LA, left atrium; LV, left ventricle; LVOT, left ventricular outflow tract; RA, right atrium; RV, right ventricle.