After recanalization and stenting a chronic total occlusion of the left anterior descending coronary artery (LAD), coronary artery perforation (CAP) was detected in the LAD (Figure 1A and Supplementary Video 1), but it was not definitive whether this CAP emptied into the pericardium (Ellis classification III) or into the right ventricle (RV) (Ellis classification III cavity spilling).1) Bedside echocardiography showed no definite pericardial effusion. Despite prolonged balloon inflation, spontaneous sealing was not achieved. To define the direction of the CAP, 2 mL of ultrasound contrast agent (UCA), Definity (Lantheus Medical Imaging, North Billerica, MA, USA) was injected into the LAD. The rapid and dense appearance of UCA in the RV on echocardiography confirmed that the CAP was connected to the RV (Figure 1B and Supplementary Video 2). Because there was felt to be no risk of cardiac tamponade the procedure was completed. The patient was hemodynamically stable at discharge and there were no subsequent complications at 1-month follow-up. Conservative management for this type of CAP is debated, but only a medium or large sized fistula is considered as a cause of heart failure and myocardial ischemia.2)

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Figure 1. Coronary angiography and contrast echocardiography. (A) Post-stenting angiography shows CAP in the LAD (white arrowheads), but it is not definitive whether this perforation emptied into the pericardium (Ellis classification III) or into the RV (Ellis classification III cavity spilling). (B) After injection of UCA into the LAD, the rapid and dense appearance of UCA in the RV on echocardiography confirms the CAP of Ellis classification III cavity spilling. CAP = coronary artery perforation; LAD = left anterior descending coronary artery; LV = left ventricle; RV = right ventricle; UCA = ultrasound contrast agent.