A rare cause of machinery murmur. Aorta to left lower pulmonary vein fistula: Is it an isolated major aortopulmonary collateral artery?

A female patient, 4 years old having Down syndrome, presented with dyspnea on exertion, repeated chest infections and precordial machinery murmur. Echocardiography, multislice CT scan (MSCT) and angiography defined the presence of an abnormal artery arising from the descending thoracic aorta and ends in the posterior segmental tributary of the left inferior pulmonary vein (LIPV). It resulted in a machinery murmur on auscultation, cardiomegaly and heart failure. A trial of trans-catheter occlusion of the arterial fistula failed. The patient was referred for surgery. Left thoracotomy and double ligation and division of the artery were done. The patient had a smooth postoperative course. The machinery murmur disappeared and the antifailure treatment was gradually withdrawn.