Ventriculocoronary Fistulas with Hypoplastic Left Heart in a
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Fistulous communications between the ventricular cavities and the coronary arterial tree can be found in the presence of hypoplasia of the left ventricle, especially when the ventricular septum is intact and mitral stenosis and aortic atresia subtype are present. The cardiac CT provides excellent anatomic information especially in the evaluation of extracardiac vessels and coronary arteries. A term baby was admitted to the neonatal intensive care unit following a cesarian delivery because of hypoxemia and respiratory distress. Transthoracic echocardiography showed HLHS with mitral stenosis and aortic atresia. There was no additional knowledge about coronary circulation. The patient immediately underwent a Sano variation of the Norwood procedure. During the operation, the left anterior descending (LAD) was seen as tortuous and aneurysmatic. The patient was stable during the early postoperative period. On the postoperative second day, the clinical status of the patient deteriorated, and electrocardiography exhibited sinus tachycardia with (ST) elevation in the left precordial leads. Electrocardiogram-gated cardiac CT was administered, and large ventriculocoronary fistulas were detected. Conventional angiography and a second operation were performed to close the ventriculocoronary fistulas that did not succeed. On the nineteenth day after the operation, the baby passed away due to heart failure.

Cardiac CT was performed on a single source 512 slices CT (Revolution CT, General Electric Healthcare, Milwaukee) using a wide detector aperture (160 mm) iterative reconstruction algorithm (ASIR-V with 50% strength) and specific reconstruction software reducing coronary motion artifacts (snapshot freeze). A prospective electrocardiogram-gated axial technique was performed within a single heartbeat for the patient. A low KV value was selected to maximize the iodine contrast to noise ratio (70 kV). Iodinated contrast medium (Omnipaque 350 mg/ml) at 2 ml per kg was intravenously administered, followed by intravenously 10 ml of saline solution. Contrast material was infused with a flow rate of 1.5 ml/s through an intravenous catheter. The scan volume was set to the whole chest, extending from the supraclavicular level superiorly to just below the diaphragm inferiorly. The center for the data acquisition phase window was set to 45% of the R-R interval due to the heart rate of the patient, which was over 160 bpm.