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Case 5: Atypical chest pain and murmur

A 28-year-old female presented with atypical chest pain and a murmur. She was not in heart failure, and had no history of previous rheumatic fever or chest trauma.

She was afebrile without any stigmata of infective endocarditis. BP, pulse pressure and central venous pressure were normal. A precordial thrill was present, and a continuous murmur was heard with maximal intensity over the apex.

Trans-thoracic colour Doppler echocardiography revealed continuous turbulence at the apex of the right ventricle, without right ventricular dilation or pulmonary hypertension.

Coronary angiography showed a severely dilated and tortuous LAD and magnetic resonance imaging confirmed the suspicion of a congenital fistula between the left anterior descending coronary artery and the right ventricle.

At surgery the presence of a severely dilated and tortuous LAD was confirmed, without evidence of dissection.

Chest pain in patients with a coronary fistula can be caused by coronary "steal", coronary dissection, or myocardial infarction.

Pre-operative stress MIBI-technetium imaging in this patient did not reveal any perfusion defects.