1. Case Presentations 10/1/07

2. Case 1 69 y.o. female, presented with burning epigastric pain, radiating to her chest PMHx -CAD s/p stents 6 years ago at OSH, no records -HTN -HL EKG: no acute changes Labs: Trop 2.87, CK 260, Relative Index 67

4. Coronary Artery Fistula Two types: A. Coronary artery to Cardiac chambers, aka coronary-cameral fistulae B. Coronary artery arteriovenous malfomation

5. Causes: -Typically from abnormal embrynic development -Also can be acquired: -trauma (stab, gunshot) -invasive cardiac procedures i.e. pacemaker implantation, cardiac biopsy Coronary Artery Fistula

7. 7 patients, all female w/ mean age 51, with demonstrated coronary-LV microfistulae from all three major arteries -6 w/ h/o stable angina, 3 with history of MI -no coronary disease by angiogram Coronary sinus lactate was measured during atrial pacing by successive increases in heart rate. -6 of the 7 patients had elevated coronary sinus lactate consistent with myocardial ischemia

8. Case 2 32 y.o. female, h/o congenital heart disease -1979, 4 y.o., surgical resection of subaortic membrane -1985, 10 y.o., large muscle bundle resected from subaortic region betwween right and left coronary cusp; supravalvular stenosis enlarged using a piece of Gortex. -Lost to follow up after 1993, seen in Adult Cardiology Clinic in 2007 with complaints of DOE and CP.

10. Anomalous RCA

13. Presentation: -Sudden death -ischemia -syncope -asymptomatic Etiology of Symptoms -cyclic compression of RCA between aorta and pulmonary artery -distorted, slit-like ostium of RCA -exercise-induced compression of the commissure between the right and left coronary cusps. Treatment: -For symptomatic patients, preferred treatment is surgical; options include: -SVG or arterial bypass -re-implantation -coronary unroofing

14. 45 y.o.h/o DM admitted with recurrent abdominal ascitis requiring large volume paracentesis every week -negative liver bx -scheduled for exploratory laporotomy -pre-op TTE performed Case 3

24. Case 4 45 y.o. female with h/o DM, HTN and positive outpatient stress test, referred for LHC.