RESUMO
The aim of this study was to evaluate the renal effects of cardiac angiography performed with three low-osmolar contrast media (CM): iopromide (IPR), ioversol (IVR) and ioxaglate (IOX). IPR and IVR are non-ionic CM, IOX is an ionic CM. Different parameters of renal function were determined before and 6, 24, 48, 72 hrs after angiography in 45 patients: 15 patients were examined with IPR, 15 with IVR and 15 with IOX. Glomerular effects--Plasma creatinine increased slightly at the 24th hour after IVR and IOX and at 48 hours after IOP. A significant increase in plasma beta2-microglobulin was observed, at the same time, only after IOX. A significant decrease in creatinine clearance was found at 6 hours after IOX. No significant variations in glomerular filtration rate (GFR) and in effective renal plasma flow were found at 48 hours after cardiac angiography; while filtration fraction was significantly reduced after IOP and IOX. Tubular effects--A marked decrease in sodium clearance and a relevant increase of urinary activities of different tubular enzymes were found after cardiac angiography with all CM, but were more evident after the ionic CM IOX, than after the two non-ionic agents. These tubular effects reached the maximum between 6 and 24 hours and returned to baseline within 72 hrs after cardiac angiography. In conclusion, slight glomerular effects were observed mainly after IOX. A reversible tubular malfunction was found with the three low-osmolar CM and was more evident after ionic CM IOX. thus suggesting that other mechanisms, besides osmolarity, play a role in tubular toxicity due to CM. In no patient did the glomerular and tubular effects of CM have a clinical relevance.
Assuntos
Meios de Contraste/efeitos adversos , Angiografia Coronária/efeitos adversos , Iohexol/análogos & derivados , Glomérulos Renais/efeitos dos fármacos , Túbulos Renais/efeitos dos fármacos , Insuficiência Renal/induzido quimicamente , Idoso , Angiografia Coronária/métodos , Feminino , Taxa de Filtração Glomerular/efeitos dos fármacos , Humanos , Iohexol/efeitos adversos , Ácido Ioxáglico/efeitos adversos , Masculino , Pessoa de Meia-Idade , Concentração Osmolar , Insuficiência Renal/enzimologia , Insuficiência Renal/urina , Fluxo Plasmático Renal Efetivo/efeitos dos fármacos , Fatores de Risco , Fatores de Tempo , Ácidos Tri-Iodobenzoicos/efeitos adversosRESUMO
The use of bilateral internal mammary artery (BIMA) grafting for myocardial revascularization has been demonstrated to provide long-term benefits compared to revascularization using single left internal mammary artery (SIMA) and venous conduits. However, it is still controversial whether the use of BIMA is associated with a higher hospital mortality and morbidity. The present study retrospectively evaluated the possible advantages related to the use of BIMA at 3-year follow-up and whether the presence of operative risk factors in patients with BIMA could limit the application of the procedure in myocardial revascularization. We compared two groups of 100 patients matched for preoperative clinical characteristics, who underwent myocardial revascularization on the left coronary system with BIMA (93 males and 7 females, mean age 59 +/- 4 years) or with SIMA and venous conduits (86 males and 14 females, mean age 63 +/- 6 years). Hospital mortality rate was 2% in both groups, the use of BIMA being not a significant risk factor for hospital mortality and morbidity. The mean follow-up was 36 +/- 6 months for the BIMA group and 40 +/- 10 months for the SIMA group. At 3 years, there was no significant differences in the actuarial freedom from cardiac death (96 +/- 2% for BIMA vs 94 +/- 2% for SIMA patients), myocardial infarction (98 +/- 2 vs 97 +/- 2%), angina (93 +/- 2 vs 91 +/- 2%), symptomatic heart failure (92 +/- 3 vs 92 +/- 2%), coronary angioplasty/reoperation (96 +/- 2 vs 97 +/- 2% ), and total cardiac events (80 +/- 4 vs 76 +/- 4%). BIMA grafting was not an independent predictor of late cardiac events. In 66 patients who underwent a late angiographic or echo-Doppler study, the patency rate was 100% for the left mammary artery, 94% for the right mammary artery and 69% for venous conduits. In conclusion, myocardial revascularization with BIMA in situ is associated with low hospital mortality and morbidity, good clinical outcome and excellent patency rate at 3 years, with apparently no significant differences when compared to the use of SIMA and venous conduits. The low hospital mortality and morbidity and the satisfactory medium-term results in our opinion justify a more extensive use of BIMA in myocardial revascularization.
Assuntos
Anastomose de Artéria Torácica Interna-Coronária/métodos , Idoso , Idoso de 80 Anos ou mais , Angiografia Coronária , Interpretação Estatística de Dados , Ecocardiografia Doppler , Feminino , Seguimentos , Humanos , Anastomose de Artéria Torácica Interna-Coronária/mortalidade , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Tempo , Veias/transplanteRESUMO
We report the case of a 57-year-old man who had presented with exertional angina early in 1997 and had subsequently undergone myocardial revascularization with the use of both internal mammary arteries. Two months after surgery, the patient was readmitted to the hospital with unstable angina. Coronary angiography revealed a 90% occlusion of the left internal mammary artery anastomosis, which was attached to the left anterior descending coronary artery. At reoperation, the left internal mammary artery was detached from the left anterior descending coronary artery, probed and injected with papaverine, checked for patency, and regrafted to the same coronary artery. Recycling of the left internal mammary artery was facilitated by the harvesting and routing technique that had been used during the previous operation. At the patient's 1-year follow-up visit, both Doppler echocardiography and coronary angiography showed patency of the recycled graft. We conclude that recycling of the left internal mammary artery is a safe and effective option in selected patients who require reoperation after myocardial revascularization.
Assuntos
Angiografia Coronária , Ecocardiografia Doppler , Oclusão de Enxerto Vascular/diagnóstico , Oclusão de Enxerto Vascular/cirurgia , Anastomose de Artéria Torácica Interna-Coronária/métodos , Angina Pectoris/cirurgia , Conservação dos Recursos Naturais , Angiopatias Diabéticas/cirurgia , Estudos de Viabilidade , Oclusão de Enxerto Vascular/diagnóstico por imagem , Humanos , Masculino , Pessoa de Meia-Idade , Recidiva , Reoperação , Fatores de Tempo , Grau de Desobstrução VascularRESUMO
BACKGROUND: The excellent results obtained with the use of the left internal mammary artery (IMA) for myocardial revascularization have led to the simultaneous use of other arterial conduits, particularly the right IMA. METHODS: The present study includes the first 100 consecutive patients with ischemic heart disease who underwent myocardial revascularization with in situ bilateral IMA grafted to branches of the left coronary artery, performed at our center. Ninety-six (96%) were males and four (4%) were females, with a mean age of 58 +/- 8 years (range, 35-75 years). The main indication for myocardial revascularization was angina in 83 patients (83%) and heart failure in 17 (17%). Seventy patients had three-vessel disease. RESULTS: Hospital mortality was 1%, with one death due to left ventricular failure. Three patients had perioperative myocardial infarction, six experienced ventricular arrhythmia, two had acute renal failure and nine respiratory insufficiency. Dehiscence of the sternal wound occurred in four patients, evolving in mediastinitis in one. All discharged patients were checked after 26 +/- 6 months (range, 12-38 months). There were two deaths, one because of cardiac failure and one sudden death, with a two-year survival rate of 97 +/- 2%. Five patients (5%) required hospitalization because of angina, and the angiographic study showed stenosis/occlusion of one or both IMAs in four cases. Thirty-five (38%) of the remaining patients underwent a coronarographic (25 patients) or transthoracic Doppler study (10 patients) to evaluate patency of the IMAs. The patency index was 100% for the left IMA and 94% for the right IMA. CONCLUSIONS: Myocardial revascularization with bilateral IMA in situ can be performed with low hospital mortality and morbidity. Sternal dehiscence is the worst complication and appears to be more frequent in diabetic and elderly patients. Mid-term results are satisfactory, with a good survival rate and freedom from major cardiac events. However, a longer follow-up is necessary to better appreciate the advantages of myocardial revascualarization with in situ bilateral IMAs.
Assuntos
Ponte de Artéria Coronária/métodos , Doença das Coronárias/cirurgia , Artéria Torácica Interna/transplante , Adulto , Idoso , Ponte de Artéria Coronária/efeitos adversos , Doença das Coronárias/fisiopatologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Análise de Sobrevida , Resultado do TratamentoRESUMO
Patch angioplasty has been reported as a suitable surgical option for patients with isolated coronary ostial stenosis, but controversy still exists concerning its effectiveness. We report the cases of 4 additional patients in whom this procedure was performed, including that of a patient with bilateral ostial stenosis; and we review the literature pertaining to bilateral ostial stenosis. Four patients, 3 with isolated stenosis of the left main coronary ostium and 1 with bilateral ostial stenosis, had direct surgical ostioplasty from January through November 1994. We considered the cause of ostial stenosis to be aortitis (of suspected syphilitic origin) in 1 patient, atherosclerotic plaque in 2 patients, and a fibrous membrane in the 4th. Ostioplasty was performed with a patch of autologous pericardium in 3 patients (fresh pericardium in 2 and glutaraldehyde-fixed in 1) and a patch of saphenous vein in 1. There were no operative deaths. One patient underwent successful reoperation for left main coronary artery restenosis after 3 months. All other patients are asymptomatic at 16, 18, and 24 months postoperatively. In the patient who underwent bilateral ostioplasty, coronary angiography showed patent ostia at 1 year. Surgical ostioplasty should be considered in the treatment of patients who have isolated ostial stenosis but no distal coronary disease. Careful patient selection seems to be a prerequisite for surgical success.
Assuntos
Angioplastia/métodos , Doença das Coronárias/cirurgia , Adulto , Idoso , Angiografia Coronária , Doença das Coronárias/diagnóstico por imagem , Vasos Coronários/cirurgia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pericárdio/transplante , Veia Safena/transplanteRESUMO
BACKGROUND: Simultaneous dobutamine stress echocardiography (DSE) and 99Tc-MIBI-SPET (DMS) for the evaluation of the presence and the extent of coronary artery disease (CAD) were assessed for a head to head comparison regarding the diagnostic acuracy of the two rests. METHODS AND RESULTS: Forty-five consecutive patients (33 males and 12 females: 53 +/- 6.8 yr.) underwent exercise electrocardiography and simultaneous dobutamine stress echocardiography and MIBI-SPET imaging. Coronary angiography was performed in all patients (significant coronary stenosis > 50%). On the basis of the results of exercise electrocardiogram the pre-test probability for coronary artery disease (Diamond's algorithm) was low (45.6 +/- 12.7%). The overall specificity, sensitivity and predictive accuracy of Echo-dobutamine stress test for diagnosis of the presence or absence of CAD were: specificity 82%, sensitivity 76%, diagnostic accuracy 80%, positive predictive value 90%, negative predictive value 40%. The overall specificity, sensitivity and predictive accuracy of MIBI-SPET-dobutamine test for diagnosis of the presence or absence of CAD were: specificity 86%, sensitivity 87%, diagnostic accuracy 84%, positive predictive value 97%, negative predictive value 54%. MIBI-SPET-dobutamine test showed a significantly higher sensitivity in comparison with ECHO-dobutamine test (P < 0.05). CONCLUSION: Both noninvasive methods for the detection of CAD showed a good diagnostic accuracy. Nevertheless the SPET model showed a higher sensitivity in comparison with DSE model, essentially in the presence of a lower extent of CAD and during submaximal test.
Assuntos
Cardiotônicos , Doença das Coronárias/diagnóstico , Dobutamina , Ecocardiografia , Tomografia Computadorizada de Emissão de Fóton Único , Meios de Contraste , Angiografia Coronária , Eletrocardiografia , Teste de Esforço , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Sensibilidade e Especificidade , Tecnécio Tc 99m SestamibiRESUMO
BACKGROUND: The incremental diagnostic value of dobutamine stress echocardiography (DSE) and 99mTc-labeled sestamibi single-photon emission computed tomography for the evaluation of the presence and extent of coronary artery disease (CAD) was assessed with ordered logistic regression and receiver-operating characteristic curves. METHODS AND RESULTS: Forty-five consecutive patients (33 men and 12 women; 53 +/- 6.8 years) underwent exercise electrocardiography and simultaneous DSE and sestamibi single-photon emission computed tomographic imaging. Coronary angiography was performed in all patients (significant coronary stenosis > 50%). On the basis of the results of exercise electrocardiography, the pretest probability for CAD (Diamond's algorithm) was low (45.6% +/- 12.7%). According to ordered logistic regression analysis, some models were estimated that performed a diagnostic accuracy level for CAD. In particular, we evaluated a clinical model (model 1) determined by the following parameters: sex, age, presence of chest pain, and positivity of electrocardiogram during dobutamine stress test. This model was 64.3% +/- 10.7% accurate for the prediction of CAD. The addition to model 1 of DSE parameters (wall motion stress and rest score index and relative difference) (model 2) yielded a diagnostic accuracy of 81.4% +/- 4.3% (p < 0.045), whereas the addition to model 1 of single-photon emission computed tomographic parameters (the difference between perfusional stress and rest score index) (model 3) improved diagnostic accuracy to 92.3% +/- 5.5% (p < 0.003), a level that appeared significantly higher than that of model 2 (p < 0.016). CONCLUSION: Both noninvasive methods for the detection of CAD showed a good diagnostic accuracy, especially when test-derived parameters were combined with clinical data. Nevertheless, the single-photon emission computed tomographic model showed a higher sensitivity compared with the DSE model.
Assuntos
Cardiotônicos , Doença das Coronárias/diagnóstico , Dobutamina , Ecocardiografia , Teste de Esforço , Tecnécio Tc 99m Sestamibi , Tomografia Computadorizada de Emissão de Fóton Único , Adulto , Idoso , Angina Pectoris/diagnóstico , Angina Pectoris/fisiopatologia , Angiografia Coronária/efeitos dos fármacos , Circulação Coronária/efeitos dos fármacos , Circulação Coronária/fisiologia , Doença das Coronárias/fisiopatologia , Eletrocardiografia/efeitos dos fármacos , Teste de Esforço/efeitos dos fármacos , Feminino , Humanos , Interpretação de Imagem Assistida por Computador , Masculino , Pessoa de Meia-Idade , Curva ROCRESUMO
In patients with previous myocardial infarction and left ventricular asynergy, dipyridamole infusion may have the capacity to unmask myocardial viability through transient recovery of contractile function in asynergic segments. The purpose of this study was to assess simultaneous changes in myocardial perfusion and LV function--elicited by dipyridamole infusion--in infarcted, asynergic segments. The echo contrast agent Albunex was injected into the left coronary artery of 19 patients (17 males, age 49-70 years) with previous myocardial infarction and baseline left ventricular asynergy, both before and after dipyridamole infusion (up to 0.56 mg.kg-1, i.v.). Analysis was not possible in three patients due to inadequate image quality and in two due to weak contrast. There were no major adverse events, or changes in vital signs or demonstrated on the electrocardiogram. After dipyridamole, 7/14 patients, showed an improvement in regional function of asynergic segments ('responders'), whereas seven patients did not ('non-responders'). Among non-responders, five had a myocardial perfusion deficit corresponding to 41% of the total left ventricular area before dipyridamole and to 38% after dipyridamole. No baseline perfusion deficits were observed in the remaining two non-responders; one of these, however, developed transient asynergy and perfusion deficit after dipyridamole. Among responders, five showed a normal perfusion pattern, both before and after dipyridamole, while the remaining two showed a perfusion deficit which markedly decreased after dipyridamole (from 32% to 13% of total left ventricular area). Thus, residual contractile reserve of asynergic, infarcted ventricular segments appears to be associated with myocardial perfusion either preserved at baseline or recruitable by a coronary dilator stimulus.
Assuntos
Albuminas , Meios de Contraste , Dipiridamol , Ecocardiografia , Infarto do Miocárdio/diagnóstico por imagem , Infarto do Miocárdio/metabolismo , Miocárdio/metabolismo , Inibidores da Agregação Plaquetária , Vasodilatadores , Disfunção Ventricular Esquerda/diagnóstico por imagem , Idoso , Sobrevivência Celular , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Contração Miocárdica , Infarto do Miocárdio/fisiopatologiaRESUMO
BACKGROUND: The incremental diagnostic information of two noninvasive tests for the detection of coronary artery disease (CAD), dipyridamole echocardiography, and exercise 201Tl myocardial scintigraphy was assessed in a series of 102 patients with ordered logistic regression and receiver-operating characteristic curves. METHODS AND RESULTS: Patients were selected from those referred to our cardiovascular centers with the clinical suspicion of CAD. After clinical evaluation, all patients underwent both noninvasive tests during hospitalization 2 weeks before coronary arteriography. The coronary arteriogram was used as a gold standard: CAD was defined as the presence of one or more vessels with 50% or greater narrowing of the luminal diameter. Clinical data were 73.0% +/- 5.7% accurate in the prediction of CAD. The addition of dipyridamole echocardiographic data to the clinical model yielded a diagnostic accuracy of 88.3% +/- 4.3% (p < 0.00001), whereas the addition of thallium scintigraphic parameters to the clinical model improved diagnostic accuracy to 93.8% +/- 2.6% (p < 0.00001). A significant increase in accuracy to 97.2% +/- 1.4% was achieved when thallium scintigraphic data were added to the clinical and dipyridamole-echocardiographic model (p < 0.00001). CONCLUSION: Both noninvasive methods for detection of CAD, DET, and ETS showed a good diagnostic accuracy especially when tests-derived parameters were combined with clinical data by means of relative logistic models; nevertheless the ETS model showed a higher sensitivity in comparison with the DET model, essentially in presence of a lower extent of CAD.
Assuntos
Doença das Coronárias/diagnóstico , Dipiridamol , Ecocardiografia , Radioisótopos de Tálio , Adulto , Idoso , Doença das Coronárias/diagnóstico por imagem , Teste de Esforço , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , CintilografiaAssuntos
Sangria/métodos , Veia Femoral , Manobra de Valsalva , Adulto , Idoso , Cateterismo/métodos , Humanos , Masculino , Pessoa de Meia-IdadeRESUMO
Cardiac Doppler Echocardiography is a suitable method for to evaluating right heart hemodynamics. However, the surgical correction of tricuspid valve annuloplasty changes valve geometry and might possibly lead to a technical obstacle to this estimation. The accuracy of Doppler echocardiography in the assessment of tricuspid regurgitation and systolic pulmonary pressure in patients who had undergone De Vega annuloplasty was evaluated in this study. Ten patients (9 females and 1 male), mean age 55.7 +/- 7.8 years, who had a previous De Vega annuloplasty for the treatment of tricuspid regurgitation due to a severe mitral stenosis, underwent a Doppler echocardiography study and, within two hours, right heart catheterization for a direct comparison of parameters calculated by different methods. Right ventricular-atrial maximal pressure gradient was found to be 32.6 +/- 11.07 mmHg by Doppler and 31.4 +/- 11.07 mmHg by catheterization. Pulmonary systolic pressure was 42.6 +/- 9.1 mmHg at Doppler and 39.1 +/- 11.3 mmHg at catheterization, with a highly significant correlation between the 2 techniques (r = 0.98%, p < 0.01). With semiquantitative Doppler evaluation 10 patients showed tricuspid insufficiency, which was mild in 8 and medium in 2. At catheterization all patients were found to have mild tricuspid insufficiency. Cardiac Doppler seems a reliable method in the evaluation of tricuspid regurgitation and of pulmonary systolic pressure even in patients who underwent De Vega annuloplasty.
Assuntos
Ecocardiografia Doppler , Insuficiência da Valva Tricúspide/diagnóstico por imagem , Valva Tricúspide/cirurgia , Função Ventricular Direita/fisiologia , Pressão Sanguínea , Cateterismo Cardíaco , Feminino , Hemodinâmica , Humanos , Masculino , Pessoa de Meia-Idade , Estenose da Valva Mitral/complicações , Estenose da Valva Mitral/cirurgia , Artéria Pulmonar/fisiopatologia , Valva Tricúspide/diagnóstico por imagem , Insuficiência da Valva Tricúspide/fisiopatologia , Insuficiência da Valva Tricúspide/cirurgiaRESUMO
False aneurysm of the internal mammary artery (IMA) is a rare complication of closure of median sternotomy by peristernal wiring. In this report a case of a false aneurysm of a branch of the internal mammary artery following a surgical repair of a complex cardiac anomaly in a patient with a previously dilated mammary artery system for pre-existing coarctation of the aorta is described. In our opinion a special attention has to be given to the course of the IMA and its collaterals whenever a median sternotomy is required to treat an aortic coarctation or its associated diseases, considering the possibility of ligation of vessels at risk of being damaged by the sutures used for closure of the sternal and rectus sheath incisions.
Assuntos
Aneurisma/etiologia , Coartação Aórtica/cirurgia , Artéria Torácica Interna , Complicações Pós-Operatórias/etiologia , Artérias Torácicas , Adulto , Doenças da Aorta/cirurgia , Insuficiência da Valva Aórtica/cirurgia , Estenose da Valva Aórtica/cirurgia , Fístula/cirurgia , Cardiopatias/cirurgia , Humanos , MasculinoRESUMO
Four examples of cardiac damage secondary to nonpenetrating trauma in road accidents are described. Two patients had interventricular septal defect and other two had tricuspid insufficiency. In all four cases the lesion was not recognized at the time of the accident but became clinically important later. The time interval between trauma and surgery was one month to thirteen years. After surgical treatment, all four patients have continued to be asymptomatic.
Assuntos
Traumatismos Cardíacos/diagnóstico , Ferimentos não Penetrantes/diagnóstico , Acidentes de Trânsito , Adolescente , Adulto , Idoso , Cateterismo Cardíaco , Cordas Tendinosas/lesões , Ecocardiografia , Feminino , Traumatismos Cardíacos/complicações , Traumatismos Cardíacos/cirurgia , Septos Cardíacos/lesões , Humanos , Masculino , Insuficiência da Valva Tricúspide/etiologiaAssuntos
Coartação Aórtica/cirurgia , Prótese Vascular , Adulto , Idoso , Aorta/cirurgia , Aorta Torácica/cirurgia , Feminino , Humanos , Masculino , Métodos , Pessoa de Meia-IdadeRESUMO
A case of congenital tricuspid incompetence in a 39 year old woman is reported. The patient, who was in suffering congestive heart failure, had no history of trauma, myocardial infarction, rheumatic fever, infective endocarditis. Right ventriculography and right atrial pressure recording both showed signs of severe tricuspid insufficiency. Echocardiography showed dilatation of the right ventricle and atrium, and the lack of normal systolic coaptation of anterior and septal tricuspid leaflets, while contrast echocardiography gave direct evidence of regurgitation. Valvular replacement with a bioprosthesis was carried out. The diagnosis of congenital tricuspid incompetence was confirmed at operation. The patient is asymptomatic at one year follow up.
Assuntos
Insuficiência da Valva Tricúspide/congênito , Valva Tricúspide/anormalidades , Adulto , Ecocardiografia , Feminino , Humanos , Insuficiência da Valva Tricúspide/diagnósticoRESUMO
The case of a 64 year-old man suffering from angina caused by neoplastic infiltration of the left anterior descending coronary artery is reported. The coronarographic examination of the vessel disclosed that it had a stenotic segment, which did not move with the cardiac contraction. An aorto-coronary by-pass vein graft relieved the symptoms.
Assuntos
Doença das Coronárias/etiologia , Neoplasias Cardíacas/complicações , Neoplasias Cardíacas/diagnóstico , Humanos , Masculino , Pessoa de Meia-IdadeRESUMO
We report the malfunction of a St. Jude Medical prosthetic valve in mitral position in a 60 year old woman. One of the two leaflets of the valve was locked in closed position because of the interference of a chorda tendinea. The patient was asymptomatic and the valve dysfunction was discovered during a routine control examination. The bi-leaflet design of this prosthetic valve appears to have offered some protection to our patient. The malfunction involved only one of the hemi-disc and the haemodynamic derangement was moderate.
Assuntos
Próteses Valvulares Cardíacas , Estenose da Valva Mitral/cirurgia , Feminino , Humanos , Pessoa de Meia-Idade , Complicações Pós-OperatóriasRESUMO
Many cases of fistulae between coronary arteries and heart chambers are now detectable because of improvement in selective coronary artery angiography. Coronary fistulae may be congenital or secondary to cardiac disease such as atrial tumors, mitral stenosis with atrial thrombosis or ventricular aneurysm. A case of a patient with rheumatic heart disease and multiple fistulae between coronary arteries and left atrium, is reported. A thin mural thrombus adherent to the left atrial wall, unsuspected preoperatively, was discovered at surgery and gave the clue to the pathological origin of the fistulae.