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Journal of the American College of Cardiology ? 2011 by the American College of Cardiology Foundation Published by Elsevier Inc.

IMAGES IN CARDIOLOGY

Vol. 57, No. 9, 2011 ISSN 0735-1097/$36.00 doi:10.1016/j.jacc.2010.04.077

Multimodality Imaging of a Coronary Artery Fistula After Septal Myomectomy in Hypertrophic Cardiomyopathy

Philip J. Garber, MD,* Farrukh Hussain, MD,* James K. Koenig, MD, Bruce Maycher, MD, Davinder S. Jassal, MD* Winnipeg, Manitoba, Canada

From the *Section of Cardiology, Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; Department of Radiology, University of Manitoba, Winnipeg, Manitoba, Canada; and the Institute of Cardiovascular Sciences, St. Boniface Research Centre, University of Manitoba, Winnipeg, Manitoba, Canada. Manuscript received March 23, 2010; accepted April 1, 2010.

A 73-year-old man with a recent septal myomectomy and coronary artery revascularization for symptomatic hypertrophic obstructive cardiomyopathy presented with newonset chest discomfort. On transthoracic echocardiography, diastolic blood flow was seen originating from the interventricular septum into the left ventricular (LV) cavity (white arrows), on both the parasternal long-axis and apical 4-chamber views (A and B, Online Videos 1 and 2). A reformatted maximum-intensity projection of a retrospectively electrocardiographically gated cardiac computed tomographic scan demonstrated a coronary artery fistula between the first septal perforator branch of the left anterior descending coronary artery and the LV (C, black arrow), confirmed by coronary angiography (D, Online Video 3).

Acquired coronary artery?to?LV fistulas can occur after surgical septal myomectomy in patients with hypertrophic obstructive cardiomyopathy. Multimodality cardiac imaging using transthoracic echocardiography, computed tomography, and catheterization is useful for diagnosis and follow-up. LA left atrium; RV right ventricle.

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