A 65-year-old female known to have type 2 diabetes mellitus, with no significant past medical history, had presented to another hospital with progressive dyspnea, orthopnea, lower limb edema in the two weeks preceding the reporting of this case. Her echocardiography revealed large pericardial effusion with echocardiographic signs of increased intrapericardial pressure. An emergency pericardiocentesis was performed. One week afterwards, she was admitted to the authors’ hospital because of re-accumulation of her large pericardial effusion, which mandated another pericardiocentesis. A CT of the chest revealed enlarged mediastinal lymph nodes (LNs). Video-assisted thoracic surgery (VATS) was done to obtain a pericardial window and a biopsy from the mediastinal LN, which revealed non-caseating granuloma, highly suggestive of sarcoidosis. A few days after surgery she experienced a neurogenic bladder, acute renal shutdown, and metabolic acidosis, during which she developed stress-induced cardiomyopathy that improved a few days later. The patient’s symptoms improved after receiving corticosteroids.

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.