Investigating a Continuous Heart Murmur

A 42-year-old male with atypical chest pain was investigated for a ²/6 continuous murmur at the apex of the heart. An electrocardiogram and a stress test were normal. Because the echocardiogram with color Doppler showed some blood flow around the apex as the only pathologic finding, a coronary fistula was suspected, but the coronary angiogram revealed completely normal coronary arteries. The computer tomogram of the chest confirmed an arterio-venous fistula around the heart’s apex which originated from the left gastric artery, but only the selective angiography (Figure 1) of the left gastric artery (white arrow) visualised the draining of the fistula into the left pulmonary artery (black arrow). As the patient was asymptomatic and signs of cardiac overload were absent, we decided to follow the patient clinically and by echocardiogram and to intervene only in case of the development of symptoms and/or left ventricular dilatation.