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tilage defects have been described with any frequency. Bronchial atresia is relatively rare as a cause of CLE,but the late asymptomatic presentation with typical radiographic features of a coin lesion makes this diagnosis more likely. The additional finding of a bronchogenic cyst is an experiment of nature which, assuming both anomalies develop at the same time, allows us to time the appearance of the atretic segment more accurately than has been possible before. 1 Warner JO, Rubin S, Heard BE. Congenital lobar emphysema: a case with bronchial atresia and abnormal bronchial cartilages. Br J Dis Chest 1982;76:177-& 2 Hislop A. Reid L. Growth and development of the respiratory system-anatomicaldevelopment. In: Davis JA, Dobbing J (eds). Scientific foundations of pediatrics. London: Heinemann 3 Schuster SR. Hanis GBC. Williams AJ, Kirkpatrick J, Reid L. Bronchial atresia: a recognizable entity in the pediatric age group. J Ped Surg 1978;13:682-89 4 Reid L. The pathology of emphysema. London: Lloyd-Luke, 1967 5 O'Rahilly R, Boyden EA. The timing and sequence of events in the development of the human respiratory system during the embryonic period proper. Z Anat Entwicklungsgesh 1973;141: 237-50 6 Erakus AJ, Griscom NT, McGovern JB. Bronchogenic cysts of the mediastinum in infancy. N Engl J Med 1964;281:1150-53 7 Binet JP, Nezelof C, Fredet J. Five cases of lobar tension emphysema in infancy: importance of bronchial malformation and value of post-operative stemid therapy. Dis Chest 1962; 41:126-32 8 Campbell PE. Congenital lobar emphysema; etiological studies. Aust Pediatr J 1960;5:226-31 9 Shafir R, J d e R. Kalter Y. Bronchiectasis: a muse of infantile lobar emphysema. J Pediat Surg 1976;11:107-12 10 Hislop A, Reid L. New pathological findings in emphysema of childhood. 1. Polyalveolar lobe with emphysema. Thorax 1970; 25682-85 Iatrogenic Fistula from the Aorta to the Left Marginal Coronary Vein* Z? john Ross, M.D.; and C w n C . jang, M.D. We report t h e first documented case of iatrogenic aortocoronary fistula to the left marginal coronary vein following coronary bypass surgery. Unique clinical data, findings from catheterization, a n d angiographic features a r e presented and compared with those in the seven previously reported cases of iatrogenic aortocoronary venous fistulae atter coronary bypass operations. A rare but recognized complication of surgery for coronary revascularization is an aortocoronary venous fistula caused by the inadvertent distal anastomosis of a saphenous vein bypass graft to a coronary vein instead of to a coronary artery. The present patient had undergone an intended bypass operation to the left circumflex or intermediate artery *From the Cardiovascular Laboratories, Loma Linda University Medical Center, Loma Linda, CA. Reprint requests: Dr long. Cardiovascular Laboratories, Room 2434, Lomo Lindo Uniwrsity Medical Center, Loma Linda, California 92354 FIGURE 1. Frame from 35-mm cineangiogram on i O O left anterior oblique projection showing "numeral-3" appearance of opacification of aortocoronary saphenous vein graft (SVG) anastomosed to proximal left marginal coronary vein (LMY)near its junction with great cardiac vein (GCV)and so con~municatingvia coronary sinus (CS) to right atrium (RA). A, distal anastomosis of saphenous vein graft. and is the first described with an iatrogenic aortocoronarv venous fistula to the left marginal coronary vein. Observed features of this case are the absence of a continuous murmur and the presence of a small shunt by oximetric studies. A @-year-oldman with recurrent pain in the chest had a history of and triplemyocardial infarction. a Vineberg prvcedure in lW, vessel coronary bypass surgery at another hospital in hlay 1982.0 1 1 physical examination, there was a short, soft systolic mllrmur at the upper left sternal border, but no continuous nlurrnilrs were detected. The electrocardiogram showed an "old" inferior mycwardial infarction. A chest roentgenogram showed persistent postoperative elevation of the left hemidiaphragm. The left ventriculogram was nor~nal. The ejection fraction was 50 percent, and the left cardiac pressures were normal. The coronary arteriogram demonstrated a proximal c~vlusionof the dominant right cwronary artery, of which the posterior descending and posterolateral branches were supplied by a patent jurnp vein graft. There was a severe proximal stenosis of the anterior descending cwronary artery. with gvod distal How via a second patent bypass graft. A moderately large unbypassed intermediate coronary artery had a significant proximal stenosis. The small left circumflex curonary artery had a severe stenosis at its origin. Contrast ~nediurn injected down a third bypass graft entered the left marginal vein close to its junction with the great cardiac vein and drained directly into the right atrium (Fig 1). Right cardiac catheterization and oximetric studies (two runs) showed normal pressures and a small but definite left-to-rightshunt at low right atrial level. The QP:QS shunt ratio was 1.4:l.O. Five published cases of aortocoronary venous fistulae were reviewed in 1982 by Przybojewski,'who added another. Subsequently, one more case has appeared,' making a total of seven. All were men aged 43 to 66 years, with angina (except one who had intractable ventricular tachycardia). Angina was relieved after surgery in four of six patients. The sites of graft insertion numbered one (one patient), two (hvo patients), three (three patients), and four (one patient). A continuous Iatrogenic Fistula from Aorta (Ross. Jeng) Downloaded From: http://journal.publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21459/ on 05/13/2017 murmur in the second or third left intercostal mace was heard in six of the seven patients. In five cases with murmurs, oximetric data were normal, but in one of these, a left-toright shunt was confirmed by a hydrogen detection electrode. The aortocoronary venous fistula involved the left anterior descending coronary vein in all six patients undergoing surgery for angina and involved the posterior interventricular coronary vein in the patient with intractable ventricular arrhythmia. Vieweg3 makes brief anecdotal mention of three further incidents, all involving the left anterior descending coronary vein. Our report is the first to describe an iatrogenic aortocoronary venous fistula to the left marginal coronary vein. It is likely that the intermediate or circumflex coronary artery was the intended target vessel. The angiogram of the fistula in the 70" left anterior oblique projection (Fig 1) resembles the arabic numeral, "3."This appearance (like that illustrated in the case reported by Vieweg3), together with rapid transit of contrast material through the coronary sinus to the right atrium, would appear to be characteristic ofan aortocoronary venous graft fistula. The absence of a continuous murmur in our patient might be explained by obesity and the deeper posterior anatomic site of the fistula. The soft systolic murmur in the present case probably originates from the patent aortocoronary bypass graft to the anterior descending coronary artery.' Our patient is unique in that a left-to-right shunt was detectable by oximetric studies. Though unexpected and of small magnitude, this shunt was apparent on two sample runs. Nevertheless, sampling error cannot be absolutely excluded; however, the majority of congenital coronary arteriovenous fistulae which drain into the right ventricle, right atrium, or coronary sinus do exhibit small shunt^.^ Furthermore, the magnitude of the shunt detected in the present case may be augmented not only by the relatively large caliber of the venous bypass graft, but also by the fact that the site of oximetric sampling could have been very close to the coronary sinus. The lack ofmurmur may also be explained by the relatively large aortocoronary venous shunt. In conclusion, we present the clinical features, data from catheterization, and angiographic findings in the first reported case of iatrogenic aortocoronary venous fistula to the left marginal coronary vein. The absence of a continuous murmur, the presence of a detectable shunt by oximetric studies, and the arabic-numeral-"3" angiographic shape of the aortocoronary venous fistula are observed features of the case. 1 Przybojewski JZ. Iatrogenic aortocoronary vein fistula: a case presentation and review of the literature. S Afr Med J 1982;62908-17 2 Hubert JW, Thanavaro S, R u b R, Connors J, Oliver GC. Saphenous vein bypass to the posterior interventricularvein: an unusual complication of coronary artery surgery. South Med J 1982; 75: 1144-46 3 Vieweg WVR. Continuous murmur following bypass surgery. Chest 1981; 79:4-5 4 Karpman L. The murmur of aortocoronary bypass. Am Heart J 1972; 83:179-81 5 Friedman WE Congenital heart disease in infancy and childhood. In: Braunwald E, ed. Heart disease: a textbook of cardiovascular medicine. Philadelphia: WB Saunders Co, 1980 graphic Abnormalities of Right Atrial Metastatic Tumors in Hepatoma* B. L. Chia, M.B.,B.S.,EC.C.P; MauriceH. Choo, M.B.,B.S.,EC.C.P;LennyTan, M.B.,B.S.; ArthurTan, M.B.,B.S.;C.]. Oon, M.D.;and E H. Chew, M.B.,B.S. We describe two patients suffering from hepatoma who presented with right atrial metastatic tumors as a result of invasion of the inferior vena cava and extension into the right atrium. Two-dimensional echocardiographic studies detected the right atrial tumor during life in both patients and the invasion of the inferior vena cava in one patient. M etastatic tumors in the right atrium as a result of direct invasion and extension up the inferior vena cava in patients suffering from hepatoma are extremely uncommon.' A 42-year-old Oriental man presented with dyspnea and abdominal swelling of two months' duration. Clinical examination revealed elevation of the jugular venous pulse up to the angle of the jaw. Auscultation of the heart revealed no abnormalities, and the blood pressure was 130185 mm Hg. Moderate ascites and mild jaundice were observed. The liver was enlarged 4 cm below the right costal margin and was hard in consistency. A chest x-ray film showed a slightly enlarged heart, and the electrocardiogram was normal. The findings from serum biochemical tests were all normal, except for a total serum bilirubin level of 3.5 mg/100 ml. During right heart catheterization the catheter could not be manipulated beyond the lower part of the inferior vena cava. Angiographic studies in this position showed total obstruction of the inferior vena cava, resulting in multiple collateral channels. Angiography with contrast dye injected at the superior vena caval-rightatrial junction showed a large mobile filling defect in the right atrium (labelled T)consistent with a tumor moving fonvard and backward across the tricuspid valve during diastole and systole (Fig IA). Selective celiac arterial angiography showed multiple vascular lesions throughout the whole liver which were typical of a hepatoma. The patient was treated medically and died two months later. Percutaneous liver biopsy, which was obtained just after death, showed hepatoma on microscopic examination. Consent for necropsy was not obtained. A 58-year-old Oriental man presented with abdominal swelling. Clinical examination revealed a markedly elevated jugular venous pulse. Auscultation of the heart was normal, and the blood pressure was 140185 m m Hg. The liver, which was enlarged 5 cm below the right costal margin, was nodular and hard. An ECG and chest x-ray film were both normal. Results of serum biochemical and hepatic function tests were all normal. The serum a-feto-protein level was grossly elevated at 650pglml. Percutaneous liver biopsy revealed hepatoma on microscopic examination. Inferior *From the Department of Medicine, National University of Singapore, Singapore (Drs. Chia, Choo, A. Tan, and Oon); the Department of Diagnostic Radiology, Singapore General Hospital, Singapore (Dr. L. Tan); and Lau King Howe Hospital, Sibu, Sarawak (Dr. Chew). Reprint requests: DI:Chia, University Department of Medicine, Singapore General Hospital, Singapore 0316 CHEST 1 87 1 3 / MARCH. 1985 Downloaded From: http://journal.publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21459/ on 05/13/2017 399