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Serendipitous Discovery of a Right Coronary Artery to Right Pulmonary Artery Fistula by Transesophageal Echocardiogram

Imaging Vignette: Although rare, coronary artery fistulae (CAF) have been described between coronary arteries and other coronary vasculature, pulmonary vasculature, and chambers of the heart. We present a serendipitous discovery of CAF via transesophageal echocardiogram (TEE) using a Siemens (Mountain View, CA, USA) Acuson Sequoia C512 machine with a multiplane esophageal probe. The images (Figs. 1–3) are obtained from a 39year old male with a history of viral nonischemic cardiomyopathy, who presented to our institute for a TEE in preparation for catheter ablation of recurrent ventricular tachycardia. Subsequent angiography confirmed a fistulous communication between right coronary artery and right pulmonary artery (Fig. 4). Although computed tomographic angiography (CTA) is now being frequently used as a diagnostic tool, studies on CAF have shown that multiplane TEE can also accurately define and provide a high quality panoramic view of the origin, course, and drainage site of coronary artery fistulae. In fact, TEE can identify the precise location of drainage site (not always seen by angiography) to aid in planning surgery. However, TEE has its own limitations. Identification of CAF is limited if a vessel is curvilinear along the epicardium, which impairs the view of the distal segments unless dilated. TEE should thus be considered complementary to angiography and may be considered an alternative to other diagnostic modalities in patients with permanent pacemaker (precluding use of