Circumflex Coronary Artery Fistulae Draining into Right Atrium: A Case Report

Coronary artery fistula (CAF) is an anomaly making a coronary artery communicate with a heart cavity or a great vessel, thus bypassing the myocardial capillary bed. CAF is frequently diagnosed as an incidental finding. Herein, we present the case of a 4-year-old boy. He was referred for a pediatric cardiology assessment due to a continuous murmur at the middle sternal border. Echocardiogram showed dilated left coronary artery and an abnormal diastolic flow in the right atrium. The right-sided chambers were slightly enlarged, but ventricular contractility was normal. CAF was suspected. Angiography and CT confirmed the diagnosis of coronary fistula from the circumflex coronary artery to the right atrium. Successful transcatheter closure with an Amplatzer PiccoloOccluder was performed with complete occlusion.

Collaterals of Life: Fistulous Communication of Vieussens’ Arterial Ring

The Vieussens’ arterial ring (VAR) is a rare coronary anomaly that may be associated with a pulmonary fistula, and has been linked to ischemia, myocardial infarction, heart failure, arrhythmias, and sudden death. We present the case of a 54-year-old man who was admitted to the emergency room with angina and dyspnea on moderate exertion, in the context of atrial fibrillation and decompensated heart failure with left ventricular systolic dysfunction. In the study of its etiology, coronary computed tomography angiography (CCTA) identified an anomalous conal artery outflow (type C) as part of the VAR and a fistula to the pulmonary artery trunk (variant 1b), with an arterial flow linking the conal artery and the middle third of the left anterior descending artery (LAD), which then fistulized to the pulmonary artery trunk. The hemodynamic and clinical repercussions presented with signs of ischemia in the LAD territory and acute heart failure. In this case, CCTA identified the coronary anomaly and its trajectory with great precision through volume rendering reconstruction, as well as the dynamics of coronary flow in the presence of the pulmonary fistula. This anatomical variant is rarely described, and CCTA is of great utility in the therapeutic decision for fistula closure.

Current characteristics of congenital coronary artery fistulas in adults:A decade of global experience

AIM:To describe the characteristics of coronary artery fistulas(CAFs) in adults,including donor vessels and whether termination was cameral or vascular. METHODS:A PubMed search was performed for articles between 2000 and 2010 to describe the current characteristics of congenital CAFs in adults.A group of 304 adults was collected.Clinical data,presentations,diagnostic modalities,angiographic fistula findings and treatment strategies were gathered and analyzed.With regard to CAF origin,the subjects were tabulated into unilateral,bilateral or multilateral fistulas and compared.The group was stratified into two major subsets according to the mode of termination;coronary-cameral fistulas(CCFs) and coronary-vascular fistulas(CVFs) . A comparison was made between the two subsets. Fistula-related major complications[aneurysm formation,infective endocarditis(IE) ,myocardial infarction(MI) ,rupture,pericardial effusion(PE) and tamponade] were described.Coronary artery-ventricular multiple micro-fistulas and acquired CAFs were excluded as well as anomalous origin of the coronary arteries from the pulmonary artery(PA) . RESULTS:A total of 304 adult subjects(47%male) with congenital CAFs were included.The mean age was51.4 years(range,18-86 years) ,with 20%older than 65 years of age.Dyspnea(31%) ,chest pain(23%) and angina pectoris(21%) were the prevalent clinical presentations.Continuous cardiac murmur was heard in 82%of the subjects.Of the applied diagnostic modalities,chest X-ray showed an abnormal shadow in 4%of the subjects.The cornerstone in establishing the diagnosis was echocardiography(68%) ,and conventional contrast coronary angiography(97%) .However,multislice detector computed tomography was performed in 16%.The unilateral fistula originated from the left in 69%and from the right coronary artery in 31%of the subjects.Most patients(80%) had unilateral fistulas,18%presented with bilateral fistulas and 2%with multilateral fistulas.Termination into the PA was reported in unilateral(44%) ,bilateral(73%) and multilateral(75%) fistulas.Fistulas with multiple origins(bilateral and multilateral) terminated more frequently into the PA(29%) than into other sites(10.6%)(P=0.000) . Aneurysmal formation was found in 14%of all subjects.Spontaneous rupture,PE and tamponade were reported in 2%of all subjects.In CCFs,the mean age was 46.2 years whereas in CVFs mean age was 55.6 years(P=0.003) .IE(4%) was exclusively associated with CCFs,while MI(2%) was only found in subjects with CVFs.Surgical ligation was frequently chosen for unilateral(57%) ,bilateral(51%) and multilateral fistulas(66%) ,but percutaneous therapeutic embolization(PTE) was increasingly reported(23%,17%and 17%,respectively) . CONCLUSION:Congenital CAFs are currently detected in elderly patients.Bilateral fistulas are more frequently reported and PTE is more frequently applied as a therapeutic strategy in adults.

Congenital solitary coronary artery fistulas characterized by their drainage sites

Last centuries have witnessed tremendous sophistication and progress in the detection,diagnosis and treatment of coronary artery fistulas(CAFs).In many countries,CAFs were reported to be visualized and treated using several imaging techniques and different management strategies.Reports from nearly all continents of the globe have contributed to the description of CAFs,not only in Asia and Europe but also throughout North and Latin America.However,these reports have to be cautiously analyzed as many of them were published as a case report and careful interpretation is warranted due to possible publication bias.A literature search was performed using PubMed search interface to select papers dealing with congenital CAFs in adult population between 2000-2009.A total of 233 subjects were collected,and analysed according to their drainage site and treatment modality.They were divided into two subgroups:percutaneous transluminal embolization group(PTE group,n=122)and surgical ligation group(SL group,n=111).In the SL group,atherosclerotic coronary artery disease(19%)and associated congenital lesions(23%)were more prevalent compared with the PTE group(9%and 8%),respectively.Infective endocarditis was more frequently seen in the SL group besides syncope,congestive heart failure and hemopericardium.In both groups multimodality diagnostic workup composed of several non-invasive and invasive imaging techniques for fistula visualization were performed and drainage sites into the different cardiac chambers and intrathoracic great vessels were similarly distributed in the two groups.

Transcatheter closure of coronary artery fistula using Guglielmi detachable coil

Background Coronary artery fistula （CAF） is a rare anomaly.Transcatheter CAF closure has been introduced using various materials,but only few data are available on the Guglielmi detachable coil （GDC）.The advantage of using GDC for transcatheter CAF closure is more controllable,therefore much safer when compared to other coils.This report is about our experience in transcatheter closure of CAF using fibered GDC in our hospital.Methods ＆ Results From 2002 to 2007,there were 10 patients with CAFs （age range：28 to 56 year-old,7 males） who underwent transcatheter CAF closure.There were a total of 19 CAFs which originated from right coronary （n =5）,left circumflex （n =3）,left anterior descending artery （n =10） and left main trunk （n =1）.Median number of coil deployment for each fistula was 3 （range：1 to 6）.The pulmonary artery was the most common site of the distal communication of CAFs （n =14）,followed by right atrium （n =3）,left atrium （n =1） and left ventricle （n =1）.Immediate coronary angiography after GDC deployment revealed no residual shunt in 12 （63.2％） CAFs,significant reduction of the flow in 5 （26.3％）,while 2 （10.5％） could not be closed due to small size.Nine （90％） patients underwent a repeated angiography within 3 to 8 months.Among 12 CAFs that were occluded immediately post-deployment,there were 2 CAFs with insignificant residual flow.Among 6 CAFs with significantly decreased flow immediately post-deployment,2 were occluded totally in the follow-up angiography.In total,12 （70.5％） CAFs were occluded completely and 5 （29.5％） CAFs still had insignificant residual flow,which did not need any additional coil deployment.During a mean follow up of 4.3 ± 0.7 year,all patients remained symptom and complication free.Conclusions The fibered GDC is a safe and effective method for percutaneous closure of the CAFs.

Incidental congenital coronary artery vascular fistulas in adults:Evaluation with adenosine-13N-ammonia PET-CT

AIM To assess the functionality of congenital coronary artery fistulas(CAFs) using adenosine stress ^(13)N-ammonia positron emission tomography computed tomography(PET-CT).METHODS Congenital CAFs were incidentally detected during coronary angiography(CAG) procedures in 11 adult patients(six males and five females) with a mean age of 64.3 years(range 41-81). Patients were collected from three institutes in the Netherlands. The characteristics of the fistulas(origin, pathway and termination), multiplicity of the origins and pathways of the fistulous vessels were assessed by CAG. Five patients underwent adenosine pharmacologic stress ^(13)N-ammonia PET-CT to assess myocardial perfusion and the functional behavior of the fistula. RESULTS Eleven patients with 12 CAFs, 10 unilateral and one bilateral, originating from the left anterior descending coronary artery(n = 8), right coronary artery(n = 2) and circumflex(n = 2). All fistulas were of the vascular type, terminating into either the pulmonary artery(n = 11) or coronary sinus(n = 1). The CAG delineated the characteristics of the fistula(origin, pathway and termination). Multiplicity of the origins and pathways of the fistulous vessels were common in most fistulas(8/12, 67% and 9/12, 75%, respectively). Multiplicity was common among the different fistula components(23/36, 64%). Adenosine pharmacologic stress ^(13)N-ammonia PET-CT revealed normal myocardial perfusion and ejection fraction in all but one patient, who showed a reduced ejection fraction.CONCLUSION PET-CT may be helpful for assessing the functional status of congenital CAFs in selected patients regarding clinical decision-making. Studies with a larger patient series are warranted.

Coronary Artery Fistula and Its Imaging Modalities—A Review Article

Coronary artery fistula (CAF) is known be a rare defect of coronary artery. When there is an abnormal pre-capillary communication between single or multiple branches of the coronary artery and any of the cardiac chambers or great vessels, it is designated as CAF. It can be found in both congenital and acquired form. Congenital origin of fistula occupies higher percentage compared to the acquired one. A wide variety of imaging modalities have been lunched to provide the best possible way to access and treat the defect. With regard to the assessment of the coronary artery fistula, trans-thoracic Doppler echocardiography and multi-slice CT (MSCT) angiography have commendable role, however, MSCTA comes in the leading position.

Coronary-cameral fistulas in adults(first of two parts)

This is a case series and review of the literature adding11 new cases.Coronary-cameral fistulas(CCFs)are infrequent anomalies which are in general co-incidentally found during diagnostic coronary angiography(CAG).To delineate the characteristics of congenital and acquired CCFs in adults,we performed a PubMed search for papers dealing with congenital or acquired CCFs in adults.Publications on coronary-vascular fistulas or paediatric subjects were not included.From the world literature,a total of 243 adult patients were identified who had congenital(65%)or acquired(35%)CCFs.In this review,which is part one of a two-part series on CCFs,we describe and discuss the congenital fistulas,give an overview on the published literature and report details of our own series of 11 patients with MMFs and solitary macro CCFs.Of the congenital group,56%were small or large solitary macro CCFs(cut-off 1.5mm)and 9%were coronary artery-ventricular multiple micro-fistulas(MMFs).Apical hypertrophic cardiomyopathy was reported in some of the reviewed subjects with MMFs(3/24=13%)but not was seen in our own series.Conservative medical management was generally the treatment of choice in congenital MMFs;prophylactic implantable cardioverter defibrillators(ICD)were implanted in 2/24(8%)of subjects,especially when extensive micro-fistulisations were involved.None of the patients of our own series required an ICD,as the MMFs were of limited size.Congenital or acquired CCFs in adults are infrequent anomalies having a wide spectrum of clinical presentation may varies from asymptomatic to severely devastating states requiring different treatment modalities.

Rare case of coronary to pulmonary vein fistula with coronary steal phenomenon

Coronary artery fistulas are abnormal connections between coronary artery territories and cardiac chambers or major vessels,most of them are congenital.Patients with coronary artery fistula can be asymptomatic or present with different symptoms like angina.Cardiac computed tomography(CT)is one of the best modalities for diagnosis.We present an elderly patient that presented with angina symptoms,non invasive stress test was positive for ischemic heart disease,coronary angiogram could not reveal any obstructive lesions,but an abnormal branch of the left descending coronary artery(LAD),cardiac CT showed fistula that connect left anterior descending coronary artery to left superior pulmonary vein.Our case is extremely rare as most of the reported cases were fistulas between LAD and pulmonary artery,but in our case the fistula between LAD and left superior pulmonary vein.In addition,our patients’symptoms resolved with anti-ischemic medical treatment without any surgical intervention.

Rare multiple fistulas with large saccular aneurysms originating from left anterior descending artery and left main coronary artery

A 49-year-old female patient consulted us for a cardiac evaluation before undergoing colon adenocarcinoma surgery. Three years prior, the patient underwent coronary angiography for dyspnea. The coronary angiography examination revealed a fistula originating from the left anterior descending artery and left main coronary artery, which had soft aneurysmal sacs and most likely drained into the pulmonary artery. Parasternal short axis echocardiography revealed a color flow that could be related to the fistula, but the other echocardiographic findings were normal. The patient did not accept the proposed examination and invasive treatment.

Cardiac tamponade as a rare complication after giant coronary fistula percutaneous closure

We present the case of an unusual complication after percutaneous closure of a giant coronary artery fis-tula. A 76-year-old man with previous admissions due to right heart failure and previous history of atrial fibrillation under acenocumarol, was admitted to our hospital for new onset of symptoms, characterized by progressive dyspnoea and peripheral edema. Physical examination revealed signs of congestive heart failure and a continuous murmur loudest along the lower sternal border. X-Ray showed cardiomegaly due to right chambers dilatation. Transthoracic echocardiography showed right chambers pressure and volume overload, with right ventricular enlargement and dysfunction, tricuspid annulus dilatation and severe tricuspid regurgitation. Cardiac catheterization showed significant elevation of right atrial pressure, as well as significant step-up of oxygen saturation in this chamber. Coronary angiography revealed the presence of a large fistula between the circumflex coronary artery (CCA) and coronary sinus (CS), with severe dilation of the CCA (maximum diameter20 mm). An Amplatzer? PDA was implanted in a distal elbow of the fistula with initailly good results. Anticoagulant therapy was then reinitiated, and a few days later, the patient developed clinical worsening of heart failure and dyspnoea. Echocardiogram showed significant pericardial effusion. Pleuropericardial window was then made draining a500 cm3 of bloody pericardial effusion. The postoperative outcome was excellent, with symptomatic relief and no signs of heart failure.

Giant Aneurysm of a Coronary-Pulmonary Artery Fistula:A Rare Cause of a Diastolic Murmur

A coronary-pulmonary artery fistula with giant aneurysmal dilatation is an extremely rare clinical constellation.The natural course of this disease and the incidence of complications are unknown.Hence,optimal treatment,particularly in asymptomatic patients,is still a matter of debate.Here we report a case of a 71-year-old asymptomatic woman with a diastolic murmur.Comprehensive cardiovascular assessments including cardiac computed tomography and invasive coronary angiography revealed a coronary-pulmonary artery fi stula with giant aneurysmal dilatation.The patient was managed conservatively and has now been followed up for 5 years without any events.

Novel treatment of coronary artery fistulae concealing severe coronary artery lesion： using thrombus aspiration catheter as a delivery guide

In this case report, we present the occlusion of multiple coronary artery fistulaes originating from proximal left anterior descending （LAD） and fight sinus valsavla and empting to the pulmonary artery at the same place. We occluded LAD fistulae by using thrombus aspira- tion catheter as a delivery guide. To the best of our knowlege, this is the first case of occlusion of coronary fistulaes with the help of throm- bus aspiration catheter. Our experience may suggest that thrombus aspiration catheters can be used in treating coronary artery fistulaes with difficult anotomv.

Surgical Correction of Coronary Artery Ectasia Combining Congenital Coronary Artery Fistula

Background:Coronary artery ectasia(CAE)complicated with concomitant congenital coronary artery fistula(CCAF)is rare.This study characterizes the clinical characteristics of CAE combining CCAF,and reports a single-institution experience with surgical correction of CAE combining CCAF.Methods:A total of 24 symptomatic patients(8 males,median 52.5 years old)who underwent surgical correction of CAE combining CCAF in this center were reviewed.Based on the size of ectatic segment,the CAE were classified as a giant CAE(>20 mm,n=14)and a non-giant CAE(≤20 mm,n=10).Individualized surgical approaches were chosen.The patients were followed up for a median of 3.8 years.Results:The overwhelming majority of CAEs were solitary,and only 4.2%of CAEs were associated with multiple lesions.CAEs were predominantly located in the right coronary artery with predilection to women more than to men(2:1).95.8%of patients with the CCAF had single fistula defect.The right atrium was the most frequent drainage site(33.3%)followed by the left ventricle(25.0%).Surgical mortality was 4.2%.All 22 follow-up patients survived with recovery from symptoms and New York Heart Association(NYHA)functional class I-II.In 10 patients with non-giant CAEs undergoing closure of fistula alone,favorable in-hospital outcomes were recorded,but residual fistula(one patient)and acute inferior wall myocardial infarction related to intracoronary thrombosis(one patient)were observed at follow-up.In 11 patients with giant CAEs undergoing aneurysm resection plus distal bypass grafting at the time of closure of fistula,favorable in-hospital outcomes and encouraging midterm results were recorded.Additionally,in 3 patients with giant CAEs undergoing closure of fistula plus aneurysmal plication,adverse events occurred,including surgical death related to rupture of the ectatic segment(one patient),perioperative myocardial infarction caused by acute thromboembolism(one patient),nonfatal inferior wall myocardial infarction related to intracoronary thrombosis(one patient)at follow-up.Conclusion:Individualized surgical approaches based on the size and the location of ectatic coronary artery as well as fistula should be offered to symptomatic patients with CAE combining CCAF.

Congenital Coronary Artery Fistula in Children:A Review of 28 Cases with Clinical and Imaging Outcomes

Background:Congenital coronary artery fistula(CCAF)is a rare anomaly.Treatment strategies tend to close the defect with a symptomatic and significant shunt,primarily based on expert consensus and case series.Results for long-term follow-up in children are limited Methods:We conducted a retrospective study to assess clinical and imaging outcomes of children with CCAF at Siriraj Hospital,Thailand during 2000–2020.Patients with single ventricle were excluded.Treatment strategies[surgical closure(SC),and percutaneous closure(PC)]were classified and the clinical outcomes at the follow-up in 2021,including coronary thrombosis,myocardial ischemia,and the results of cardiovascular imaging were reviewed.Results:Twenty-eight children with CCAF were included in the study.The median age at diagnosis was 2.5 years(2 days–18 years).Presenting symptoms were audible murmur(82%)and heart failure(35%).Most of fistulae arose from the right coronary artery(12/28)and exited at the right atrium(11/28).In recent visits(0.5–14 years follow-up),six patients with asymptomatic small CCAF were managed by watchful follow-up without complications.PC was primarily treated in 11 children:7 underwent successful procedures;1 had a residual shunt and required re-intervention;1 had ischemic symptoms immediately after the procedure with left coronary occlusion that required device removal plus SC and 2 were technically unable to place the device,requiring SC.Four patients were waiting for interventions(1 PC and 3 SC).Cardiovascular imaging surveillance that followed closure demonstrated asymptomatic thrombus formation in three patients(1 PC and 2 SC).No mortality presented.Conclusion:CCAF with significant shunt is indicated to close either SC or PC.Ischemic events are rare but have been reported after closure.In addition,thrombus formation should be watched for post-intervention.Surveillance with cardiovascular imaging is recommended after defect closure(ideally 1–5 years post closure),or at interval follow-ups in patients with symptoms to evaluate possible recanalization,thrombus,or ischemia.Life-long clinical and echocardiographic follow-up is warranted.Watchful follow-up is acceptable for hemodynamically insignificant fistula without complication in the series.

Intermittent appearance of right coronary fistula and collateral circulation:A case report

BACKGROUND Congenital coronary artery fistula can lead to symptoms of chest tightness,chest pain,or exertional dyspnea,which is a congenital vascular malformation that should not be ignored.Patients who have such malformations are frequently observed with different concurrent abnormal anatomic structures.Collateral circulation may have a positive effect on improving the patients'symptoms.CASE SUMMARY A 53-year-old female experienced episodic chest discomfort for the past month with symptoms manifesting when she was agitated or overexerted.After a positive treadmill test,the patient underwent coronary angiography.“Ghostlike”intermittent appearance of coronary ventricular fistula and collateral branching were observed.The patient was diagnosed with a right coronary ventricular fistula and collateral circulation.CONCLUSION This case shows the likelihood of collateral circulation in patients with coronary artery fistula.This may provide medical staff with novel solutions to treat insufficiency of myocardial blood supply induced by cardiovascular malformations.

Congenital coronary artery fistulas complicated with pulmonary hypertension: Analysis of 211 cases

AIM To compare the behavior of pulmonary hypertension(PHT) associated with coronary artery fistulas(CAFs) between the Asian and Caucasian subjects.METHODS CAFs may be complicated with PHT secondary to leftto-right shunt. Literature review limited to the English language. A total of 211 reviewed patients were collected. Of those, 111 were of Asian and 100 were of Caucasian ethnic origin. The mean age of the Asian and the Caucasian groups of patients were 48.9(range 19-83) and 49.9 years(range 16-85), respectively. In both groups, right heart catheterization was the most commonly(95%) used method for determining pulmonary artery pressure. RESULTS From all of the reviewed subjects, PHT was found in 49 patients(23%), of which 15 were Asian and 34 were Caucasian. In 75% of PHT subjects, mild to moderate PHT was reported and 76% of the fistulas had a vascular mode of termination. Treatment was surgical in 61%, followed by percutaneous therapeutic embolization(27%) and finally conservative medical management in 12% of PHT subjects. PHT was associated with a slight female gender predominance. The majority demonstrated mild to moderate PHT. PHT was reported more frequent in the Caucasian compared with the Asian ethnicity group. The majority of fistulas in patients with PHT had a vascular mode of termination. The results of this review are intended to be indicative and require cautious interpretation.CONCLUSION The likelihood for a CAF patient to develop PHT is presented when possessing the following features, with a Caucasian female having a fistula with a vascular mode of termination.

Acquired Coronary Cameral Fistula Due to Post Stent Balloon Dilatation: Dual Coronary Artery Perforations into the Left Ventricle—What Is the Right Treatment?

A fifty-year-old female with recent history of LAD stent placement for instent restenosis, presented with chest pain and ventricular fibrillatory arrest. Angiography revealed total occlusion of her LAD stent. She underwent IVUS study, balloon angioplasty and stent placements. Post balloon dilatation of the under-deployed distal stent resulted in dual coronary artery perforations with extravasation of contrast into the LV cavity, a Type 4 Ellis coronary artery perforation (CAP). No extravasation was noted into the pericardium. Immediately a covered stent was deployed which completely sealed both perforation sites with resultant TIMI grade 3 flow. Under-deployment of stents is a common occurrence and is underappreciated. It can happen due to various reasons. Not many options exist at that time but to use a high pressure balloon and post dilate the stent. One rare complication is CAP due to post stent dilatation, with incidence reported as 0.1% to 3.0% of PCI procedures. Among the various type of CAP, Ellis Type 4 is of the least frequent however no studies have looked at its exact incidence rate. Prompt recognition and quick intervention are essential to good patient outcome. We chose to deploy a covered stent over the perforation with interim balloon tamponading. Deployment of the stent successfully sealed both the CAPs. Remarkably the patient remained stable and did not complain of chest pain throughout the procedure. The patient did well;she was discharged on dual antiplatelet therapy and is continuing to do well. We report a rare case of 2 distal LAD perforations that drained into the LV (an Ellis Type 4 CAP) caused by post stent dilatation that were successfully treated with a single covered stent. We report successful management of this case along with review of literature about management and dilemmas encountered is such instances.

A Rare Case of Transcatheter Closure of Both Inlet and Outlet of a Left Coronary Artery-to-Left Ventricular Fistula with Giant Coronary Artery Aneurysm

A congenital coronary artery fistula(CCAF)combined with giant coronary aneurysm(CAA)is a rare congenital cardiac abnormality.We reported an 8-year-old patient who underwent transcatheter closure of both inlet and outlet of a proximal left coronary artery(LCA)-to-left ventricular(LV)fistula with CAA of 41 mm×28 mm in diameter,during which acute occlusion of left anterior descending coronary artery(LAD)occurred immediately after device implantation at the inlet of fistula.We managed to prevent the patient from major adverse cardiac events by conservative therapy with dual antiplatelet agents instead of surgical removal of the device.The patient recovered well and had been follow-up for 2 years with no late complications reported.

Assessment of Right Coronary Artery Fistula by Multiplane Transesophageal Echocardiography

Coronary artery fistula(CAF) is a relatively uncommon cardiovascular disease. It is an abnormal communication between a coronary artery and a cardiac chamber, great vessels, or other vascular structures. Most are congenital. Multiplane transesophageal echocardiography(multiplane TEE. MTEE) can reveal the proximal dilation, the course and the drainage site of CAF. Presented in this paper was a report of right coronary artery-left ventricle fistula , for the first time,right coronary-left ventricle fistula diagnosed by MTEE and confirmed by angiography.