- Email: [email protected]
Doppler color flow imaging in coronary artery fistula
1180
Brief Communications
are being developed, but data are still scarce on their efficacy and safety. Thus rapid percutaneouslaserablation of the emboli could represent a therapeutic alternative for selected patients. Results of in vitro studies1y2have shownthat thrombus ablation can be achieved by laser irradiation. Continuous-wave lasersare effective’ but producethermal damageto the adjacent tissues’l*l2with their risks of spasm13 and thrombosisr2.Conversely, pulsed delivery of laser energy can be usedfor tissueablation without thermal injury.‘l This study demonstratesthat pulsed dye laser irradiation can provide effective rapid percutaneousrecanalization of fresh (0 30 minutes) venous thrombosis.Sham experiments demonstrated that laser recanalization was not solely the result of mechanicaldisplacementof the clot by the laser catheter, even though the finding of pulmonary emboli (albeit much smaller than the original clot size) suggeststhat thrombus migration and embolization may participate in laser recanalization. The mechanismof clot removal is not known, but the absenceof thermal injury and the ability of the laserto induce shockwavesin liquids5 suggesta mechanical process.Laser-induced perforations were frequent (5 of 12 laser-treated animals).The absence of thermal injury in the vesselwall after laser treatment, suggeststhat these perforations were due to improper guidanceof laserablation rather than to extensive thermal injury adjacent to the site of irradiation.l’, l2 Use of a balloon-tipped laser catheter to center the laser fiber in the vessellumen could prevent perforation. Although laser-induced pulmonary emboli were frequent, their size was smallboth in absolutevalues (lessthan or equal to 3 mm2) and when comparedwith the emboli produced in group 3. In conclusion,pulsed dye laser irradiation permits rapid catheter recanalization of venousthrombus in vivo without thermal injury. It may be more rapid than thrombolysis; however, the risk of perforation issignificant. Theseresults were obtained in straight small-caliber vesselsobliterated by freshthrombus. Their applicability to tortuous and wide pulmonary arteries occluded by older more organized venous emboli remains to be determined. Finally, in this acute experiment the risk of rethrombosisis unknown, although experimental data suggestthat the pulsed dye laserreducesadhesionof platelets to injured vessels.i5Thus the pulsed dye laser deservesfurther study in the treatment of venous thrombosis and pulmonary embolism. We thank Y. Rio and Technomed International(Paris,France) for technical support and R. Cannon for helpful comments.
REFERENCES
1. Lee G, Ikeda RM, Stobbe D, et al. Effects of laser irradiation on human thromhus: demonstration of a linear dissolutiondose relation between clot length and energy density. Am J Cardiol 1983;52:876-7. 2. LaMuraglia GM, Anderson RR, Parrish JA, Zhang D, Prince MR. Selective laser ablation of venous thrombus: implications for a new approach in the treatment of pulmonary embolus. Lasers Surg Med 1988;8:486-93. 3. Prince MR, LaMuraglia GM, Teng P, Deutsch TF, Anderson RR. Preferential ablation of calcified arterial plaque with la-
American
4.
October 1991 Heart Journal
ser-induced plasmas. IEEE J Quantum Electronics 1987;QE23:1783-6. Dupe RJ, English PD, Smith RAG, Green J. The evaluation of plasmin and streptokinase activator complexes in a new rabbit model of venous thrombosis. Thromb Hemos 1981. 46:528-34. Bell CE, Landt JA. Laser-induced high pressure shock waves in water. Ann1 Phvsiol Lett 1967:10:46-51. Meyer G, Charbonnier B, Stern M, Brochier M, Sors H. Thrombolysis in acute pulmonary embolism. In: Julian D, Kubler W, Norris RM, Swan HJC, Collen D, Verstraete M, eds. Thrombolysis in cardiovascular diseases. New York: Marcel Dekker, 1989;337-60. Gray HH, Miller GAM, Paneth M. Pulmonary embolectomy: its place in the management of pulmonary embolism. Lancet 1988;1:1441-5. Greenfield LJ, Langham MR. Surgical approaches to thrombo-embolism. Br J Surg 1984;71:968-70. Kensey KR, Nash JE, Abrahams C, Zarins CK. Recanalization of obstructed arteries with a flexible rotating tip catheter. Radiology 1987;165:387-9. Bildsoe MC, Moradian GP, Hunter DW, Castaneda-Zuniga WR, Amplatz K. Mechanical clot dissolution: new concept. Radiology 1989;171:231-3. Deckelbaum LI. Isner JM. Donaldson RF. et al. Reduction of laser induced pathologic tissue injury using pulsed energy delivery. Am J Cardiol 1985;56:662-7. Isner JM, Steg PG, Clarke RH. Current status of cardiovascular laser therapy. IEEE J Quantum Electron 1987;QE-23:175671. Steg PG, Gal D, Rongione AJ, et al. Effect of argon laser irradiation on rabbit aortic smooth muscle: evidence for endothelium independent contraction and relaxation. Cardiovasc Res 1988;22:747-53. Petitpretz P, Simmoneau G, Cerrine J, et al. Effects of a single dose of urokinase in patients with life-threatening pulmanary emboli: a descriptive trial. Circulation 1984;70:861-6. Gregory KW, Flotte T, Michaud N, Fallon JT. Laser-induced inhibition of platelet adhesion [Abstract]. Circulation 1989; 8O(suppl II):II-523. -3
5. 6.
7. 8. 9. 10. 11. 12. 13.
14. 15.
“.
Doppler cokr flow imaging in coronary artery fistula Ming-Shien Wen, MD, Fun-Chung Lin, MD, San-Jou Yeh, MD, and Delon Wu, MD. Taipei,
Taitoan,
Republic
of China
Coronary artery fistula is a rare anomaly, usually presenting asa precordial continuous murmur at an atypical site.i The diagnosisis dependent upon cardiac catheterization and angiography. With the advent of two-dimensional echocardiography and Doppler echocardiography, and especially after the innovation of Doppler color flow imaging, From the Section Memorial Hospital, This study the Republic
of Cardiology, Chang Gung
was supported by a grant from the National of China (NSC 79-0412.B182-37).
Reprint requests: Fun-Chung 199 Tung Hwa North Road, 414130567
Department of Medicine, Medical School.
Lin, Taipei,
MD, Chang Gung Taiwan, Republic
Chang
Science Memorial of China.
Gung
Council Hospital,
of
Volume Number
122 4.
Part
1
Brief Communication-~
118 1
Fig. 1. Two-dimensional Doppler color flow imaging, pulsed Doppler echocardiogram,and angiogramin caseNo. 1. A, Parasternal short-axis view color imaging showing an aneurysmally dilated right coronary artery (RCA) arising from the aorta (Ao) with continuous flow during both systoleand diastole (red color). PA, Pulmonary artery. B, Modified apical four-chamber view color imagingshowingthe fistulous vessel(Fi) coursingat the level of the atrioventricular groove and draining into the right ventricle (RV) below the tricuspid anulus (An). Arrow indicates the site of drainagewith a continuous flow (blue color). LV, Left ventricle. C, Pulsed Doppler echocardiogramwith the samplevolume at the site of drainage showing a continuous flow during both systole and diastole. D, Angiogram posterior-anterior view with contrast media injected into the right coronary sinusshowingthe right coronary artery arising from the right sinusof Valsalva, becominganeurysmally dilated, and then draining into the posterior inferior aspectof the right ventricle by a small fistulous vessel,as indicated by the arrowhead.
the diagnosisof coronary artery fistula can be made noninvasively with identification of the fistula from its origin through its courseto the site of drainage.2-4Herein we report three casesof coronary artery fistula in which the accurate diagnosis was made by echocardiography. The Doppler color flow features, including the origin, the course,and the drainage site, are described. Two-dimensional Doppler echocardiography and color flow imaging studies were performed using a 3.5 MHz phased array transducer (Hewlett-Packard model 77020A HewlettPackard Co., Medical Products Group, Andover, Mass.) Doppler echocardiography was displayed by placing an operative-control movable sampling volume on a two-dimensionalcolor flow imaging frame; the echocardiograms were recorded on a videotape and strip-chart recorder. Included in this study were three female patients aged 18, 21, and 36 years, respectively. CasesNo. 1 and 2 had
palpitations and caseNo. 3 had no symptoms; all had a precordial continuousmurmur. In caseNo. 1, the parasternal short-axis view of the two-dimensionalechocardiogram showeda dilated right coronary artery, originating from the right sinusof Valsalva (Fig. 1, A), coursingto the posterior aspectof the right ventricle and connecting with the right ventricle just below the tricuspid valve anulus with a small-caliber fistulous vessel (Fig. 1, B). Continuous turbulent flow of the fistulous vesseldraining into the right ventricle was clearly demonstrated on color flow imaging. The flow was toward the transducer and originated from the aorta through a large right coronary sinus of Valsalva before draining into the right ventricle belowthe tricuspid anulus (Fig. 1, C). The aortogram showedan aneurysmally dilated right coronary artery arising from the right sinusof Valsalva, circling around the aorta, turning to the right anterior and lateral atrioventricular groove, and then drain-
1182
Brief Communications
American
October tQQ1 Heart Journal
Fig. 2. Two-dimensional Doppler color flow imaging, pulsed Doppler echocardiogram,and aortogram in caseNo. 2. A, Parasternal short-axis view color imaging showingan aneurysmally dilated fistulous vessel (Fi) coursing around the back of the aorta (Ao) and draining into the right atrium (RA), asindicated by the arrow. B, Pulsed Doppler echocardiogramwith the samplevolume in the right atrium showinga continuous flow during systoleand diastole. C, Aortogram in the lo-degree right anterior oblique view showing a fistulous vessel(Fi) arising from the noncoronary sinus of Valsalva traversing behind the aorta (Ao), heading toward the right atrium, and becominganeurysmally dilated before draining into the roof of the right atrium. LCA, Left coronary artery.
ing into the posterior inferior surfaceof the right ventricle below the tricuspid anulus (Fig. 1, D). This wassimilar to what wasdemonstratedby echocardiography. The ratio of pulmonary-to-systemic flow was 2.0 by oxygen saturation study. The patient underwent a surgical closure of the fistula and the diagnosiswas confirmed. In case No. 2, the two-dimensional echocardiogram demonstrateda dilated vesselfrom the left sideof the aorta coursing around the back of the aorta and with an aneurysmal dilation behind the right atrium (Fig. 2, A). The Doppler color flow imaging study showed a continuous turbulent flow originating from the left side of the aorta and draining into the right atrium (Fig. 2, A and B). The aortogram revealed a dilated vesselarising from the noncoronary sinus of Valsalva, emanating to the back of the aorta and then becoming aneurysmally dilated before draining into the right atrium (Fig. 2, C). The ratio of pulmonary-to-systemic flow was 2.2 by oxygen saturation study. The patient underwent a surgical closureof the fistula and the diagnosiswas confirmed.
In caseNo. 3, the two-dimensional echocardiogramdid not show any abnormal vascular structure. However, the pulsedDoppler echocardiogramdetected a continuousflow in the main pulmonary artery immediately distal to the left pulmonary cusp.The Doppler color flow imaging study detected two small turbulent flows on each side of the main pulmonary artery (Fig. 3, A and B). Selective left coronary angiography revealed that the left coronary artery was normal at its origin. A tortuous vesselarosedistal to the origin of the left coronary artery and drained into the left side of the main pulmonary artery (Fig. 3, C). Selective right coronary angiography showeda secondvesselarising from the right coronary artery and draining into the right sideof the main pulmonary artery (Fig. 3, D). The ratio of pulmonary-to-systemic flow was 1.2 by oxygen saturation. This patient did not undergo surgicalclosureof the fistula becausethe small shunt was asymptomatic. Two-dimensional echocardiography can visualize dilated fistulous vesselsin patients with coronary artery fistulas.2 Both pulsed and continuous wave Doppler
Volume
122
Number
4, Part
1
Brief Communications
1183
3. Two-dimensional Doppler color flow imagingand coronary arteriogram in caseNo. 3. A, Parasternal short-axis view color imaging during systole showing a flow away from the transducer (blue color) in the main pulmonary artery (PA) just distal to the pulmonary valve, as indicated by the arrow. Ao, Aorta; LA, left atrium. B, Parasternal short-axis view color flow imagingduring diastole showinga secondflow toward the transducer (red color) in the main pulmonary artery just distal to the pulmonary valve, as indicated by the arrow. C, Selective left coronary arteriogram in the 30-degreeright anterior oblique view showinga fistulous vessel($5) arising from the left coronary artery (LEA) proximal to the diagonalbranch and draining into the main pulmonary artery. D, Selective right coronary arteriogram in posterior-anterior view showing a fistulous vesselarising from the right coronary artery (RCA) and draining into the main pulmonary artery. Fig.
echocardiography can further detect the direction of flow within the fistula; they can alsodetect the continuous turbulent flow at the site of drainage into the cardiac chamber.3p4The Doppler color flow imaging study, as illustrated in this report, makesthe detection of the drainage site of the fistula easier and clearer than the conventional Doppler study, especially when the draining site is small or when more than one fistula is present.5p 6 REFERENCES
1. Upshaw CB Jr. Congenital coronary arteriovenous fistula. Report of a case with an analysis of seventy-three reported cases. AM HEART J 1962;63:399-404. 2. Yoshikawa J, Katao H, Yanagihara K, Takagi Y, Okumachi F, Yoshida K, Tomita Y, Fukaya T, Baba K. Noninvasive visu-
alization of the dilated main coronary arteries in coronary artery fistulas by cross-sectional echocardiography. Circulation 1982;65:600-3. 3. Agastston AS, Chapman E, Hildner FJ, Samet P. Diagnosis of a right coronary artery-right atria1 fistula using two-dimensional and Doppler echocardiography. Am J Cardiol 1984; 54:238-9. 4. Fang BR, ChiangCW, Lin FC, Lee YS, ChangCH. Twodimensional and Doppler echocardiographic features of coronary arteriovenous fistula. J Ultransound Med 1990;9:39-43. 5. Ludomirsky A, Danford DA, Glasow PF, Blumenschein SD, Murphy DJ, Huhta JC. Evaluation of coronary artery fistula by color-flow Doppler echocardiography. Echocardiography 198?;4:383-6. 6. Trask JL, Bell A, Usher BW. Doppler color flow imaging in detection and mapping of left coronary artery fistula to right ventricle and atrium. J Am Sot Echocardiogr 1990,3:131-4.
Brief Communications
are being developed, but data are still scarce on their efficacy and safety. Thus rapid percutaneouslaserablation of the emboli could represent a therapeutic alternative for selected patients. Results of in vitro studies1y2have shownthat thrombus ablation can be achieved by laser irradiation. Continuous-wave lasersare effective’ but producethermal damageto the adjacent tissues’l*l2with their risks of spasm13 and thrombosisr2.Conversely, pulsed delivery of laser energy can be usedfor tissueablation without thermal injury.‘l This study demonstratesthat pulsed dye laser irradiation can provide effective rapid percutaneousrecanalization of fresh (0 30 minutes) venous thrombosis.Sham experiments demonstrated that laser recanalization was not solely the result of mechanicaldisplacementof the clot by the laser catheter, even though the finding of pulmonary emboli (albeit much smaller than the original clot size) suggeststhat thrombus migration and embolization may participate in laser recanalization. The mechanismof clot removal is not known, but the absenceof thermal injury and the ability of the laserto induce shockwavesin liquids5 suggesta mechanical process.Laser-induced perforations were frequent (5 of 12 laser-treated animals).The absence of thermal injury in the vesselwall after laser treatment, suggeststhat these perforations were due to improper guidanceof laserablation rather than to extensive thermal injury adjacent to the site of irradiation.l’, l2 Use of a balloon-tipped laser catheter to center the laser fiber in the vessellumen could prevent perforation. Although laser-induced pulmonary emboli were frequent, their size was smallboth in absolutevalues (lessthan or equal to 3 mm2) and when comparedwith the emboli produced in group 3. In conclusion,pulsed dye laser irradiation permits rapid catheter recanalization of venousthrombus in vivo without thermal injury. It may be more rapid than thrombolysis; however, the risk of perforation issignificant. Theseresults were obtained in straight small-caliber vesselsobliterated by freshthrombus. Their applicability to tortuous and wide pulmonary arteries occluded by older more organized venous emboli remains to be determined. Finally, in this acute experiment the risk of rethrombosisis unknown, although experimental data suggestthat the pulsed dye laserreducesadhesionof platelets to injured vessels.i5Thus the pulsed dye laser deservesfurther study in the treatment of venous thrombosis and pulmonary embolism. We thank Y. Rio and Technomed International(Paris,France) for technical support and R. Cannon for helpful comments.
REFERENCES
1. Lee G, Ikeda RM, Stobbe D, et al. Effects of laser irradiation on human thromhus: demonstration of a linear dissolutiondose relation between clot length and energy density. Am J Cardiol 1983;52:876-7. 2. LaMuraglia GM, Anderson RR, Parrish JA, Zhang D, Prince MR. Selective laser ablation of venous thrombus: implications for a new approach in the treatment of pulmonary embolus. Lasers Surg Med 1988;8:486-93. 3. Prince MR, LaMuraglia GM, Teng P, Deutsch TF, Anderson RR. Preferential ablation of calcified arterial plaque with la-
American
4.
October 1991 Heart Journal
ser-induced plasmas. IEEE J Quantum Electronics 1987;QE23:1783-6. Dupe RJ, English PD, Smith RAG, Green J. The evaluation of plasmin and streptokinase activator complexes in a new rabbit model of venous thrombosis. Thromb Hemos 1981. 46:528-34. Bell CE, Landt JA. Laser-induced high pressure shock waves in water. Ann1 Phvsiol Lett 1967:10:46-51. Meyer G, Charbonnier B, Stern M, Brochier M, Sors H. Thrombolysis in acute pulmonary embolism. In: Julian D, Kubler W, Norris RM, Swan HJC, Collen D, Verstraete M, eds. Thrombolysis in cardiovascular diseases. New York: Marcel Dekker, 1989;337-60. Gray HH, Miller GAM, Paneth M. Pulmonary embolectomy: its place in the management of pulmonary embolism. Lancet 1988;1:1441-5. Greenfield LJ, Langham MR. Surgical approaches to thrombo-embolism. Br J Surg 1984;71:968-70. Kensey KR, Nash JE, Abrahams C, Zarins CK. Recanalization of obstructed arteries with a flexible rotating tip catheter. Radiology 1987;165:387-9. Bildsoe MC, Moradian GP, Hunter DW, Castaneda-Zuniga WR, Amplatz K. Mechanical clot dissolution: new concept. Radiology 1989;171:231-3. Deckelbaum LI. Isner JM. Donaldson RF. et al. Reduction of laser induced pathologic tissue injury using pulsed energy delivery. Am J Cardiol 1985;56:662-7. Isner JM, Steg PG, Clarke RH. Current status of cardiovascular laser therapy. IEEE J Quantum Electron 1987;QE-23:175671. Steg PG, Gal D, Rongione AJ, et al. Effect of argon laser irradiation on rabbit aortic smooth muscle: evidence for endothelium independent contraction and relaxation. Cardiovasc Res 1988;22:747-53. Petitpretz P, Simmoneau G, Cerrine J, et al. Effects of a single dose of urokinase in patients with life-threatening pulmanary emboli: a descriptive trial. Circulation 1984;70:861-6. Gregory KW, Flotte T, Michaud N, Fallon JT. Laser-induced inhibition of platelet adhesion [Abstract]. Circulation 1989; 8O(suppl II):II-523. -3
5. 6.
7. 8. 9. 10. 11. 12. 13.
14. 15.
“.
Doppler cokr flow imaging in coronary artery fistula Ming-Shien Wen, MD, Fun-Chung Lin, MD, San-Jou Yeh, MD, and Delon Wu, MD. Taipei,
Taitoan,
Republic
of China
Coronary artery fistula is a rare anomaly, usually presenting asa precordial continuous murmur at an atypical site.i The diagnosisis dependent upon cardiac catheterization and angiography. With the advent of two-dimensional echocardiography and Doppler echocardiography, and especially after the innovation of Doppler color flow imaging, From the Section Memorial Hospital, This study the Republic
of Cardiology, Chang Gung
was supported by a grant from the National of China (NSC 79-0412.B182-37).
Reprint requests: Fun-Chung 199 Tung Hwa North Road, 414130567
Department of Medicine, Medical School.
Lin, Taipei,
MD, Chang Gung Taiwan, Republic
Chang
Science Memorial of China.
Gung
Council Hospital,
of
Volume Number
122 4.
Part
1
Brief Communication-~
118 1
Fig. 1. Two-dimensional Doppler color flow imaging, pulsed Doppler echocardiogram,and angiogramin caseNo. 1. A, Parasternal short-axis view color imaging showing an aneurysmally dilated right coronary artery (RCA) arising from the aorta (Ao) with continuous flow during both systoleand diastole (red color). PA, Pulmonary artery. B, Modified apical four-chamber view color imagingshowingthe fistulous vessel(Fi) coursingat the level of the atrioventricular groove and draining into the right ventricle (RV) below the tricuspid anulus (An). Arrow indicates the site of drainagewith a continuous flow (blue color). LV, Left ventricle. C, Pulsed Doppler echocardiogramwith the samplevolume at the site of drainage showing a continuous flow during both systole and diastole. D, Angiogram posterior-anterior view with contrast media injected into the right coronary sinusshowingthe right coronary artery arising from the right sinusof Valsalva, becominganeurysmally dilated, and then draining into the posterior inferior aspectof the right ventricle by a small fistulous vessel,as indicated by the arrowhead.
the diagnosisof coronary artery fistula can be made noninvasively with identification of the fistula from its origin through its courseto the site of drainage.2-4Herein we report three casesof coronary artery fistula in which the accurate diagnosis was made by echocardiography. The Doppler color flow features, including the origin, the course,and the drainage site, are described. Two-dimensional Doppler echocardiography and color flow imaging studies were performed using a 3.5 MHz phased array transducer (Hewlett-Packard model 77020A HewlettPackard Co., Medical Products Group, Andover, Mass.) Doppler echocardiography was displayed by placing an operative-control movable sampling volume on a two-dimensionalcolor flow imaging frame; the echocardiograms were recorded on a videotape and strip-chart recorder. Included in this study were three female patients aged 18, 21, and 36 years, respectively. CasesNo. 1 and 2 had
palpitations and caseNo. 3 had no symptoms; all had a precordial continuousmurmur. In caseNo. 1, the parasternal short-axis view of the two-dimensionalechocardiogram showeda dilated right coronary artery, originating from the right sinusof Valsalva (Fig. 1, A), coursingto the posterior aspectof the right ventricle and connecting with the right ventricle just below the tricuspid valve anulus with a small-caliber fistulous vessel (Fig. 1, B). Continuous turbulent flow of the fistulous vesseldraining into the right ventricle was clearly demonstrated on color flow imaging. The flow was toward the transducer and originated from the aorta through a large right coronary sinus of Valsalva before draining into the right ventricle belowthe tricuspid anulus (Fig. 1, C). The aortogram showedan aneurysmally dilated right coronary artery arising from the right sinusof Valsalva, circling around the aorta, turning to the right anterior and lateral atrioventricular groove, and then drain-
1182
Brief Communications
American
October tQQ1 Heart Journal
Fig. 2. Two-dimensional Doppler color flow imaging, pulsed Doppler echocardiogram,and aortogram in caseNo. 2. A, Parasternal short-axis view color imaging showingan aneurysmally dilated fistulous vessel (Fi) coursing around the back of the aorta (Ao) and draining into the right atrium (RA), asindicated by the arrow. B, Pulsed Doppler echocardiogramwith the samplevolume in the right atrium showinga continuous flow during systoleand diastole. C, Aortogram in the lo-degree right anterior oblique view showing a fistulous vessel(Fi) arising from the noncoronary sinus of Valsalva traversing behind the aorta (Ao), heading toward the right atrium, and becominganeurysmally dilated before draining into the roof of the right atrium. LCA, Left coronary artery.
ing into the posterior inferior surfaceof the right ventricle below the tricuspid anulus (Fig. 1, D). This wassimilar to what wasdemonstratedby echocardiography. The ratio of pulmonary-to-systemic flow was 2.0 by oxygen saturation study. The patient underwent a surgical closure of the fistula and the diagnosiswas confirmed. In case No. 2, the two-dimensional echocardiogram demonstrateda dilated vesselfrom the left sideof the aorta coursing around the back of the aorta and with an aneurysmal dilation behind the right atrium (Fig. 2, A). The Doppler color flow imaging study showed a continuous turbulent flow originating from the left side of the aorta and draining into the right atrium (Fig. 2, A and B). The aortogram revealed a dilated vesselarising from the noncoronary sinus of Valsalva, emanating to the back of the aorta and then becoming aneurysmally dilated before draining into the right atrium (Fig. 2, C). The ratio of pulmonary-to-systemic flow was 2.2 by oxygen saturation study. The patient underwent a surgical closureof the fistula and the diagnosiswas confirmed.
In caseNo. 3, the two-dimensional echocardiogramdid not show any abnormal vascular structure. However, the pulsedDoppler echocardiogramdetected a continuousflow in the main pulmonary artery immediately distal to the left pulmonary cusp.The Doppler color flow imaging study detected two small turbulent flows on each side of the main pulmonary artery (Fig. 3, A and B). Selective left coronary angiography revealed that the left coronary artery was normal at its origin. A tortuous vesselarosedistal to the origin of the left coronary artery and drained into the left side of the main pulmonary artery (Fig. 3, C). Selective right coronary angiography showeda secondvesselarising from the right coronary artery and draining into the right sideof the main pulmonary artery (Fig. 3, D). The ratio of pulmonary-to-systemic flow was 1.2 by oxygen saturation. This patient did not undergo surgicalclosureof the fistula becausethe small shunt was asymptomatic. Two-dimensional echocardiography can visualize dilated fistulous vesselsin patients with coronary artery fistulas.2 Both pulsed and continuous wave Doppler
Volume
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Number
4, Part
1
Brief Communications
1183
3. Two-dimensional Doppler color flow imagingand coronary arteriogram in caseNo. 3. A, Parasternal short-axis view color imaging during systole showing a flow away from the transducer (blue color) in the main pulmonary artery (PA) just distal to the pulmonary valve, as indicated by the arrow. Ao, Aorta; LA, left atrium. B, Parasternal short-axis view color flow imagingduring diastole showinga secondflow toward the transducer (red color) in the main pulmonary artery just distal to the pulmonary valve, as indicated by the arrow. C, Selective left coronary arteriogram in the 30-degreeright anterior oblique view showinga fistulous vessel($5) arising from the left coronary artery (LEA) proximal to the diagonalbranch and draining into the main pulmonary artery. D, Selective right coronary arteriogram in posterior-anterior view showing a fistulous vesselarising from the right coronary artery (RCA) and draining into the main pulmonary artery. Fig.
echocardiography can further detect the direction of flow within the fistula; they can alsodetect the continuous turbulent flow at the site of drainage into the cardiac chamber.3p4The Doppler color flow imaging study, as illustrated in this report, makesthe detection of the drainage site of the fistula easier and clearer than the conventional Doppler study, especially when the draining site is small or when more than one fistula is present.5p 6 REFERENCES
1. Upshaw CB Jr. Congenital coronary arteriovenous fistula. Report of a case with an analysis of seventy-three reported cases. AM HEART J 1962;63:399-404. 2. Yoshikawa J, Katao H, Yanagihara K, Takagi Y, Okumachi F, Yoshida K, Tomita Y, Fukaya T, Baba K. Noninvasive visu-
alization of the dilated main coronary arteries in coronary artery fistulas by cross-sectional echocardiography. Circulation 1982;65:600-3. 3. Agastston AS, Chapman E, Hildner FJ, Samet P. Diagnosis of a right coronary artery-right atria1 fistula using two-dimensional and Doppler echocardiography. Am J Cardiol 1984; 54:238-9. 4. Fang BR, ChiangCW, Lin FC, Lee YS, ChangCH. Twodimensional and Doppler echocardiographic features of coronary arteriovenous fistula. J Ultransound Med 1990;9:39-43. 5. Ludomirsky A, Danford DA, Glasow PF, Blumenschein SD, Murphy DJ, Huhta JC. Evaluation of coronary artery fistula by color-flow Doppler echocardiography. Echocardiography 198?;4:383-6. 6. Trask JL, Bell A, Usher BW. Doppler color flow imaging in detection and mapping of left coronary artery fistula to right ventricle and atrium. J Am Sot Echocardiogr 1990,3:131-4.