A 65-year-old woman presented to the emergency department feeling feverish and having dyspnea. A chest X-ray revealed multifocal nodular consolidation, indicating possible embolic infarction. Transthoracic echocardiography revealed vegetation attached to the aortic valve (Fig. 1A, arrow), resulting in moderate aortic regurgitation (see Supplementary Video 1, 2 in the online-only Data Supplement). Additionally, unusual flow originating from the right sinus of Valsalva was noted (Fig. 1B, asterisks and arrows, see Supplementary Video 3 in the online-only Data Supplement). The right ventricular (RV)-focused apical 4-chamber view revealed an oscillating echogenic mass attached to the RV inferoseptal wall (Fig. 1C, arrow). Color Doppler imaging revealed a turbulent flow draining to the RV from an uncertain dilated structure. The previously detected echogenic mass was found to be located at the point of fistulous drainage and considered vegetation (Fig. 1D: arrow head for fistula, asterisk for uncertain dilated structure, arrow for vegetation; Supplementary Video 4 in the online-only Data Supplement). A coronary computed tomographic angiography was immediately performed, revealing the presence of a giant right coronary artery (RCA, Fig. 1E) and combined coronary to RV fistula and vegetation (Fig. 1F: arrow heads for fistula, asterisk for giant RCA, arrow for vegetation). Final coronary angiography confirmed coronary to RV fistula, which originated from the distal RCA (Fig. 1G, arrowhead, see Supplementary Video 5 in the online-only Data Supplement). Surgery to remove the infected tissue and correct the coronary fistula, along with a concomitant aortic valve replacement, was recommended. The operative findings (Fig. 1H) were generally consistent with the preoperative diagnosis. The patient recovered from postoperative care without further clinical deterioration. Our case emphasizes the need for multimodality imaging in patients having infective endocarditis combined with complex structural heart disease.
Fig. 1.
Footnotes
The authors have no financial conflicts of interest.
Supplementary Materials
The online-only Data Supplements are available with article at https://doi.org/10.4070/kcj.2016.0268.
Oscillating echogenic masses are attached to the aortic valve, suggestive of vegetation.
Combined moderate aortic regurgitation is noted. Additionally, unusual flow near the sinus of Valsalva is demonstrated.
Two-dimensional echocardiographic imaging (left) and corresponding color Doppler imaging (right) are suggestive of a giant right coronary artery originating from the right sinus of Valsalva.
Two-dimensional echocardiographic imaging and corresponding color Doppler imaging demonstrates a coronary artery fistula draining to the right ventricle. A dilated structure located at the 7 o'clock direction turns out to be a giant RCA. Note the turbulent fistula flow from the giant RCA to the right ventricle and combined vegetation on the RV wall. RCA: right coronary artery, RV: right ventricular.
Right coronary angiogram demonstrates a giant and tortuous right coronary artery and concomitant coronary to right ventricle fistula.
Associated Data
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Supplementary Materials
Oscillating echogenic masses are attached to the aortic valve, suggestive of vegetation.
Combined moderate aortic regurgitation is noted. Additionally, unusual flow near the sinus of Valsalva is demonstrated.
Two-dimensional echocardiographic imaging (left) and corresponding color Doppler imaging (right) are suggestive of a giant right coronary artery originating from the right sinus of Valsalva.
Two-dimensional echocardiographic imaging and corresponding color Doppler imaging demonstrates a coronary artery fistula draining to the right ventricle. A dilated structure located at the 7 o'clock direction turns out to be a giant RCA. Note the turbulent fistula flow from the giant RCA to the right ventricle and combined vegetation on the RV wall. RCA: right coronary artery, RV: right ventricular.
Right coronary angiogram demonstrates a giant and tortuous right coronary artery and concomitant coronary to right ventricle fistula.