Combination of anatomic and perfusion imaging for decision making in a professional soccer player with giant coronary artery to left ventricle fistula

Excerpt

A 24-year-old professional level male soccer player underwent systematic cardiovascular evaluation required by the French Soccer Federation, as recommended by the guidelines for competitive sports.1 He had no relevant family or personal medical history, and no cardiovascular risk factors. He was asymptomatic and physical examination showed an excellent general condition, normal blood pressure (112/77 mm Hg), a heart rate of 60 bpm, and a normal cardio-pulmonary examination, without any murmurs or abnormal bruits. The electrocardiogram was normal. Trans-thoracic echocardiography (TTE) first suggested a possible coronary artery to left ventricle fistula, showing an abnormal color Doppler flow through the left ventricle wall to the mid part of the ventricular cavity (Figure 1). Left ventricular systolic and diastolic functions were normal, without any cavitary dilatation or LV hypertrophy (end diastolic wall thickness = 11 mm). A 64-slice cardiac computed tomography (CT) demonstrated the presence of a coronary artery left ventricle fistula, with the three-dimensional volume-rendered image showing a highly developed left anterior descending artery with a diameter, anastomosis to left ventricular, of 8 mm (Figure 2A, B). A coronary angiography confirmed a giant coronary left ventricular fistula without any coronary artery stenosis (Figure 3). Investigations were completed by an exercise test by ²⁰¹Thallium single-photon emission computed tomography (SPECT) and exercise TTE for detecting myocardial ischemia. Bicycle exercise stress test reached a maximum workload of 225 W (170 pbm, 87% of maximal predicted heart rate, maximum blood pressure 190/80 mmHg). Both tests were normal without any evidence of presence of ischemia (Figure 4). Finally, a 24 hour-Holter demonstrated the complete absence of arrhythmias.

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