Sinus of Valsalva Fistula to the Right Ventricle along with Coronary Artery Fistula to the Pulmonary Artery in a Young Native American Female

Sinus of Valsalva aneurysm is a rare condition and associated with a high rate of mortality if rupture occurs. The aneurysms are rarely diagnosed until rupture occurs. This case describes a young Native American female whose only symptom was intermittent chest pain prior to the detection of the aneurysm along with a small ventricular septal defect. The patient was also found to have a coexisting coronary artery fistula, and it is rare phenomenon to have these coexisting anomalies. The anomalies were demonstrated on both cardiac computed tomography and coronary angiography. The patient underwent surgical closure of both anomalies, which is the recommended treatment to avoid future complications. 1. Introduction Sinus of Valsalva fistulas was first described in 1839. The incidence of sinus of Valsalva fistulas ranges considerably in previously conducted studies form 0.14% to 0.96% [1–3]. In one study by Takach and colleagues, the most common site of origin was the right coronary sinus with rupture into the right ventricle. Ventricular septal defects were an associated finding in 11.6% of cases, which was a finding in our patient. The absolute indications for surgical intervention in a ruptured fistula include right ventricular outflow obstruction, infection, arrhythmias, or coronary artery obstruction [4]. However, the literature is less definitive regarding the optimal management for asymptomatic, nonruptured fistulas. 2. Case Presentation A 32-year-old Native American female was referred to cardiology for a newly diagnosed heart murmur and a history of previously diagnosed congenital heart disease. The patient reported atypical chest pain intermittently upon awakening but denies any palpitations or dyspnea. The patient had been diagnosed with a cardiac abnormality and murmur at birth, but she believed the murmur and abnormality had resolved. The patient was previously diagnosed with mild developmental delay, hyperthyroidism, and asthma. She lives with her parents and denies any alcohol or drug use. There was no family history of congenital heart disease. Clinical examination revealed a 3/6 systolic murmur at the left lower sternal border radiating to the apex. A continuous, high-pitched, and diastolic murmur was also were noted at the left sternal border. The transthoracic echocardiogram showed an intracardiac shunt from the right coronary sinus of Valsalva to the right atrium creating inward movement towards the right atrium of the tricuspid valve during systole. The echocardiogram also revealed mild to moderate tricuspid regurgitation, right atrial