ABSTRACT
The patient, a 45-year-old female renal transplant recipient, presentedwith chest pain accompanied by shortness of breath,which is precipitated by exertion, and relieved by rest. She did not have any symptoms of congestive heart failure. Her family historywas significant for hypertension and hyperlipidemia. She had been attending hemodialysis three-times a week for 8 years for chronic renal failure. She had been undergoing hemodialysis through a temporary double lumen subclavian catheter for 1 week due to the nonfunctioning dialysis fistula. The electrocardiogram (ECG) revealed sinus rhythm with T-wave inversion in leads II, III, and aVF. The transthoracic echocardiography (TTE) showed an ejection fraction of 55%, normal cardiac chamber dimensions, and impaired inferior wall motion, which might be associated with coronary fistulae. TTE also showed minimal tricuspid, and mitral regurgitation. The patient was advised to undergo CA, based on symptoms and findings consistent with the coronary artery disease. The CA was performed using the standard femoral approach with a 6-Fr diagnostic catheter. The CA revealed mild plaques in the left anterior descending artery and left circumflex artery (Figs. 1–2). In the left anterior oblique view, fistulas were seen between proximal right coronary artery (RCA) and right atrium. In right anterior oblique view, the small localized contrast staining was seen, which was consistent with the perforation of distal three branches of RCA (Figs. 3–5). The ECG was obtained due to the new-onset chest pain. It showed no change from previous ECG. The cardiac panel showed that CK-MB levels were minimally elevated, and troponin-I levels were normal. The TTE revealed a small pericardial effusion without tamponade. She was admitted to the coronary intensive care unit for follow-upmonitorization. The pericardial effusion did not change during a 48-hour follow-up. The patient was advised to undergo percutaneous coil embolization of fistulas of RCA by our heart team. Shewas referred to the tertiary cardiovascular center.
