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VSD being a left-to-right shunt tends to increase with increase in SVR and decrease in PVR, thus leading to increased pulmonary blood flow, pulmonary hypertension, and consequently reversal of shunt leading to Eisenmenger's syndrome.
The echocardiogram revealed three left-to-right shunts including an ASD, ventricular sepal defects (VSD) and a large PDA.
The abnormal vessel, as detected in our patient, may arise from the coronary artery at any level, (6) and the hemodynamic effect of the left-to-right shunt is related to the size of the shunt and pulmonary vascular resistance.
Medical management of left-to-right shunt lesions includes anticongestive therapy and nutritional supplements.
A left-to-right shunt is also more common among migraine-with-aura patients.
CAF can result in coronary steal and left-to-right shunt which may further reduce the ventricular perfusion and increase diastolic volume overload.5 The factors influencing the clinical presentation and prognosis of the coronary to pulmonary artery fistula (CPAF) are the size of the communication, the amount of blood drained through it, the resistance of the recipient chamber, and development of myocardial ischaemia or infarction.6 The clinical diagnosis of coronary artery-pulmonary artery fistulae is difficult because clinical presentation, laboratory and ECG manifestations are usually nonspecific.
This results in a "steal phenomenon" causing chronic myocardial ischemia and symptoms related to chronic left-to-right shunt. This may also result in ventricular dilatation and dysfunction with the severity depending on the shunt size, the number of collaterals, the territory at risk, and the overall myocardial oxygen demands [11, 12].
It is generally considered that these patients often develop significant congestive heart failure due to a large left-to-right shunt, and surgical repair should be carried out in the first several months of life.[sup][11] In our series, 31 of 36 patients aged <1 year recovered uneventfully.
An absent "step up" in saturation ruled out a left-to-right shunt. A TTE with ASCT was repeated and performed in reversed Trendelenburg position demonstrating a strongly and obvious right-to-left shunt through a PFO (Figure 1).
In particular, increased pulmonary flow and increased pulmonary artery pressure in patients with PAA due to the left-to-right shunt raise the risk of rupture.
Ventricular septal defect is an acyanotic congenital heart disease, characterized by a left-to-right shunt. The incidence varies between two and six per 1000 live births.
Coronary fistula closure is indicated in symptomatic patients especially with heart failure or myocardial ischemia, and in asymptomatic patients with large or increasing left-to-right shunt. (4, 11) In our series, two patients were asymptomatic, two had ischemic manifestations explained by an associated atherosclerotic coronary disease and only one patient had symptomatic large fistulas that require closure.