Introduction: Coronary artery fistula (CAF) is a rare cardiac anomaly that typically presents as a continuous murmur in an otherwise asymptomatic patient. Occasionally, it can result in congestive heart failure or bacterial endocarditis. Objective: To better delineate the course of coronary artery fistula for the first time, using the SonoVue contrast agent during transthoracic echocardiography. Method and results: A referred 46-year-old male with a known history of dyspnea on exertion for a period of almost three months was admitted to the hospital with progressive dyspnea, and assessed under suspicion of CAF. CAF, was seen with a coronary angiogram, but the exact entry point in the left ventricle or left atrial wall could not be determined.CT angiography also failed to establish the exact point of entrance to LV (left ventricle), so CAG (coronary angiography) was repeated with SonoVue contrast agent injected into LM (Left main) while using a Siemens echocardiography machine. Multiple views were obtained during the injection, and revealed unusual flow in the left ventricle just below the PML (posterior mitral leaflet) postero-lateral and passing through the fistula to LV. Conclusion: Contrast Enhanced Echocardiography is thought to be more sensitive and in affording an accurate delineation of CAF drainage into cardiac chambers, and can be utilized in a direct precise and safe way.

Introduction: Coronary artery fistula (CAF) is a rare cardiac anomaly that typically presents as a continuous murmur in an otherwise asymptomatic patient. Occasionally, it can result in congestive heart failure or bacterial endocarditis. Objective: To better delineate the course of coronary artery fistula using an intracoronary injection of SonoVue contrast agent, whilst performing transthoracic echocardiography. Method and results: A referred 46-year-old male, with a history of exertional dyspnea for almost three months, was admitted to the hospital with progressive dyspnea, and assessed under suspicion of CAF. CAF was seen with a coronary angiogram, but the exact entry point in the left ventricle or left atrial wall could not be determined. CT angiography also failed to establish the drainage site , so CAG (coronary angiography) was repeated with the SonoVue contrast agent injected into LM (Left main) while using a Siemens echocardiography machine. Multiple views were obtained during the injection and revealed unusual flow in the left ventricle just below the PML (posterior mitral leaflet) and passing through the fistula to LV. Conclusion: Contrast-Enhanced Echocardiography by direct intracoronary injection of SonoVue contrast agent, is safe and can aid in the delineation of fistula drainage.