Right coronary artery-to-right ventricle fistula in a pediatric patient evaluated by 64-detector-row computed tomographic coronary angiography.

A 2-year-old girl in whom a cardiac murmur had been detected at the age of 4 months underwent physical examination. She had no cyanosis, but a continuous murmur was detected. The murmur was centered in the 4th right intercostal space and radiated vertically. The echocardiogram showed right coronary artery (RCA) dilation. We sedated the patient and obtained computed tomographic (CT) images by use of contrast-enhanced electrocardiographic-gated multidetector computed tomographic (MDCT) angiography. A 64-slice CT scanner (Siemens Sensation 64; Erlangen, Germany) (120 kV, 35 mA) was used, with a detector configuration of 64 × 0.6 mm and a reconstruction interval of 0.6 × 0.4 mm. We administered 2 mL/kg of nonionic iodinated contrast medium at 2 mL/sec through the antecubital vein; a threshold of 100 Hounsfield units was used to trigger the diagnostic image acquisition. The scan time was 3.4 seconds, with an effective radiation dose of 1.3 mSv. The MDCT coronary angiograms showed RCA dilation with a fistula to the posterobasal region of the right ventricle (RV) (Figs. 1, ​,22 and ​and3).3). The fistula was closed successfully with an intraluminal occlusion device (AMPLATZER® Duct Occluder, AGA Medical Corporation; Plymouth, Minn), as shown on invasive coronary angiograms (Figs. 4 and ​and55). Fig. 1 Volumetric multidetector computed tomographic image shows aneurysmal dilation of the right coronary artery and its drainage into the right ventricle. Fig. 2 Maximum-intensity projection image from multidetector computed tomographic angiography shows the fistulous trajectory of the right coronary artery and its drainage into the basal portion of the right ventricle. Fig. 3 Multiplanar reconstruction from multidetector computed tomographic angiography shows the trajectory of the right coronary artery. The distal segment of the artery has a normal diameter (arrowhead), and the proximal segment is dilated (arrow) and ... Fig. 4 Invasive coronary angiography shows aneurysmal dilation of the right coronary artery and drainage into the right ventricle. The distal segment of the artery has a normal diameter. Fig. 5 Invasive coronary angiography after transcatheter closure of the fistula with an intraluminal occlusion device. The fistulous trajectory that was seen before treatment (arrowhead) is totally occluded.