Coronary Artery Fistulae

Two patients presented to our cardiology clinicMr. H was 70 years old with a history of cardiac transplantation for ischemic cardiomyopathy. He presented with worsening dyspnea. Two years ago, he could run up 2 flights of stairs but had recently started to become short of breath while walking short distances. He also described pedal edema and progressive orthopnea. His medical history was significant for coronary artery disease. On examination, we noted an elderly male (6′0″; 85 kg). The heart rate was 90 bpm with a blood pressure of 156/90 mm Hg. The SaO2 was 98% on room air. The heart sounds were normal, but we auscultated a III/VI continuous machinery murmur over the left upper sternal border. His ECG showed sinus rhythm and left ventricular hypertrophy. The chest radiograph displayed mild cardiomegaly. We performed a transthoracic echocardiogram that was remarkable for concentric left ventricular hypertrophy with normal ejection fractions. Right heart catheterization revealed normal filling pressures and cardiac output. An endomyocardial biopsy showed no evidence of allograft rejection.Ms. B was 75 years old and also presented with dyspnea. For the past 4 months, she had noted shortness of breath after walking ≈1 mi, whereas she was able to go much farther on her daily walks before the onset of symptoms. Her medical history was significant for hypertension, dyslipidemia, and migraines. There was no previous history of cardiac disease. On examination, we noted a frail elderly female (5′6″; 50 kg). Her heart rate was 62 bpm with a blood pressure of 132/90 mm Hg. The SaO2 was 99% on room air. The heart sounds were again normal but we auscultated 2 murmurs—one was a II/VI continuous murmur over the left upper sternal border and the other was a II/IV diastolic decrescendo murmur best heard in the aortic area. The …