PMC6370176_01
A: Coronary angiogram showing a total occlusion lesion from the second bend of the RCA. B: The guidewire had been wrongly placed in the RV. The arrow indicates the entry site from the RCA to RV. The white dotted lines indicate the true direction of the PDA and PLA according to the calcium shadows. A jet of contrast (arrows) leaking out from the distal CTO lesion immediately after the 2.0 mm dilated balloon both at systolic phase (C) and diastolic phase (D). Dynamic images can be seen in Video 1. CTO = chronic total occlusion, PDA = posterior descending artery, PLA = posterior lateral artery, RCA = right coronary artery, RV = right ventricle.
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F1
The right coronary artery (RCA) was also totally occluded from the second bend and was supplied through a few collateral paths from the LAD (Fig. 1A). The guidewire went through the occluded lesion and got to the distal part of the "post lateral artery" (PLA), which later proved to be in the right ventricle (RV) chamber (Fig. 1B). The followed cine showed that the contrast had flushed out from the distal RCA lesion (Fig. 1C and D, Video 1).
A: An apical four chamber view showing the guidewire signal in the RV chamber (arrow) and the suspected fistulous flow (arrows) in the diastole phase (B) and systole phase (C) in the tricuspid valve region of the RV. It is of importance to note that the flow is more pronounced in the diastole phase and less, but continuous, through the systole phase. Dynamic images can be found in Video 2. LA = left atrium, LV = left ventricle, RA = right atrium, RV = right ventricle.
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F2
A very strong echo signal was detected in the RV from the guidewire (Fig. 2A), which confirmed the existence of the perforation. The Doppler flow seemed more pronounced in the diastole phase and less, but continuous, through the systole phase (Fig. 2B and C, Video 2).