Coronary artery fistula: a review

A Rare Case of a Giant Coronary Sinus with Focal Aneurysm Secondary to Multiple Fistulous Connections Arising from a Dilated, Tortuous Left Circumflex Coronary Artery

•TTE adds value in the diagnosis of a coronary artery-to-coronary sinus fistula. •AV fistula was observed via two connections between the LCx and coronary sinus. •Multimodality imaging aids in the diagnosis of coronary artery fistula.

Transcatheter Closure of Congenital Coronary Artery Fistulas with a Giant Coronary Artery Aneurysm in Children: Experiences from a Single Center

Background:

Transcatheter closure of congenital coronary artery fistulas (CCAFs) is an alternative therapy to surgery; however, data regarding transcatheter closure for CCAF with a giant coronary artery aneurysm (CAA) in pediatric patients are still limited due to the rarity of the disease. We aimed to evaluate the efficacy and safety of transcatheter closure for CCAF with a giant CAA in a pediatric population at a single center.

Methods:

Medical records of pediatric patients (<18 years old) who underwent transcatheter closure of CCAF with a giant CAA between April 2007 and September 2016 at Guangdong Cardiovascular Institute (Guangdong, China) were reviewed.

Results:

Twelve patients (median age, 6.1 years; range, 1.9–11.0 years) underwent successful transcatheter closure procedures. One patient underwent closure at both the entry and exit points of the CAA, three patients underwent closure at the exit point of the CAA, and eight patients underwent closure at the entry point of the CAA. After a mean follow-up of 7.2 years (range, 0.5–9.8 years), one patient (with closure at the exit point of the CAA) underwent transcatheter re-intervention because of a significant residual shunt. She eventually underwent a surgical procedure due to aneurysm dilation after the second intervention. One patient experienced thrombus formation within the CAA after the procedure. Among those with closure at the entry point of the CAA, a mild-to-moderate residual shunt was detected in three patients.

Conclusions:

Transcatheter closure appears to be a safe and effective alternative therapy for CCAF with a giant CAA in the pediatric population. Closure at the entry point of the CAA, and closure at both the entry and exit points when feasible, may reduce the risk of postinterventional complications.

Surgical treatment for a case of coronary steal from a traumatic coronary artery-cameral fistula after blunt cardiac injury

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Traumatic coronary artery-cameral fistula (TCAF) is rare after blunt chest trauma.

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Development of coronary steal and reversible ischemia can occur with TCAF.

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Disease can progress to cardiomyopathy and heart failure.

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Treatment involves early diagnosis with transcatheter or surgical interventions for ligation and revascularization.

Introduction

Blunt cardiac trauma covers a spectrum of injuries from clinically insignificant myocardial contusions to lethal ruptures of cardiac valves and chambers. Traumatic coronary artery-cameral fistulas (TCAF) are a rare sequelae of blunt chest trauma.

Case presentation

A 53-year-old male developed a TCAF after a motor vehicle collision. He was found on admission to be in cardiogenic shock with an elevated troponin and intermittent bifascicular block. An echocardiogram revealed hypokinesis of the mid-anteroseptal myocardium with an ejection fraction of 50%. Cardiac catheterization revealed a pseudoaneurysm of the left anterior descending artery (LAD) with a fistulous connection to the right ventricle, shown to be associated with reversible anterior wall ischemia from distal LAD coronary steal phenomenon on a nuclear perfusion scan. Given the ischemic burden, he was treated with operative revascularization via a single vessel coronary artery bypass graft (CABG) using the left internal mammary artery to LAD.

Discussion

Early repair of TCAF can halt the progression of complications like left-to-right shunting, pulmonary hypertension, and heart failure. The two best described operative approaches to surgical closure of the fistula are either via external ligation or direct repair from within the recipient chamber, possibly with bypass grafting distal to the fistula site. Transcatheter closure and conservative management has been described for select patients with iatrogenic fistulas in recent literature.

Conclusion

High levels of clinical suspicion are necessary for the early detection and intervention of TCAF. Surgical or transcatheter interventions including fistula ligation and CABG can prevent later complications of heart failure.

Cardiac Computed Tomography as an Imaging Modality in Coronary Anomalies

Coronary artery fistulae and coronary aneurysms are rare anomalies. When they become symptomatic, they require precise anatomic information to allow for planning of the therapeutic procedure. We report a case in which both fistulae and aneurysm were present. The required information could only be obtained by electrocardiogram-gated computed tomography with reformation. This imaging modality should be considered in every case of fistula or coronary aneurysm.

Coronary Artery Fistulas: Case Series and Literature Review

Congenital coronary artery fistulas are rare anomalies. As coronary angiography and multidetector computed tomography have become more accessible, they have been increasingly used in the investigation of chest pain and heart failure. Coronary artery fistulas are often an incidental finding, which raises the question of how patients with this condition should be managed. Intervention with either transcatheter closure or surgical closure is often technically possible. Many patients are asymptomatic early after closure. However, follow-up studies have shown post-closure sequelae, such as residual leakage, thrombosis with or without myocardial infarction, and coronary stenosis. Therefore, there has been a shift from intervention towards watchful waiting in asymptomatic patients. In this article, we review the published literature on the natural history and treatment outcomes in individuals with coronary artery fistulas. We present case reports from our clinic and discuss the management of incidental findings of coronary artery fistulas.

CT coronary angiography findings in non-atherosclerotic coronary artery diseases

Non-atherosclerotic coronary artery diseases are being increasingly recognised as causes of acute coronary events. Invasive coronary angiography frequently fails to identify the abnormalities in the proximal course of coronary arteries and coronary wall, while computed tomography coronary angiography (CTCA) allows for acquisition of more detailed information. CTCA serves as a reliable method for evaluating patients with non-atherosclerotic coronary artery diseases. The purpose of this article is to provide an overview of non-atherosclerotic abnormalities that may be demonstrated on CTCA.

Transcatheter coil embolization of iatrogenic coronary artery-left ventricle fistula after mitral valve replacement

Acquired causes of coronary fistulas are rare disorders and may develop following coronary atherosclerosis, infection, or trauma (iatrogenic). Iatrogenic coronary fistulas may be acquired secondary to surgical or nonsurgical interventions. We describe a case of an iatrogenic coronary artery-left ventricle fistula following mitral valve replacement surgery, presented with ventricular arrhythmia and heart failure. In a unique technique, we implanted three coils with the aid of a Scepter C balloon with inflation at the ostial portion of the left circumflex artery.

Preoperative evaluation of coronary artery fistula using dual-source computed tomography

OBJECTIVES

To evaluate the efficacy of dual-source computed tomography (DSCT) in assessing the morphological features, quantitative features, and associated coronary artery lesions among patients with coronary artery fistula (CAF) before surgery.

METHODS

We enrolled 34 patients with CAF that were morphologically and quantitatively analyzed by DSCT and compared the analyses with surgical results (reference standard). The associated coronary artery lesions were also assessed.

RESULTS

By DSCT, we identified 15 patients (44.1%) with left-sided CAF, 9 (26.5%) with right-sided CAF, and 10 (29.4%) with bilateral CAF; the left anterior descending coronary artery (50.0%) was most frequently involved. Drainage was most commonly in the main pulmonary artery (41.2%), and those with right-sided CAF had larger feeding coronary arteries and drainage sites than those with left-sided or bilateral CAF (p<0.05). All the morphological features presented by DSCT were confirmed at surgery. In the quantitative analysis of CAF, DSCT was as accurate as surgery (r=0.95-0.98, p<0.001), and it was able to evaluate associated lesions accurately, including arteriosclerotic plaques, coronary artery aneurysms, and myocardial bridges. The evaluation could be completed in a single scan, without requiring an increased radiation dose (mean ED=2.27±1.92mSv).

CONCLUSIONS

DSCT is an alternative noninvasive imaging method that enables accurate assessment of morphological features, quantitative features, and associated coronary artery lesions in patients with CAF. It can be used to provide comprehensive information for determining surgical strategies.

Bilateral coronary artery fistulas with a giant coronary aneurysm complicated by aneurysm rupture: A case report

RATIONALE

Coronary artery aneurysms and fistulas are not rare conditions in clinical practice, but bilateral fistulas with a giant coronary aneurysm in just one person are quite rare.

PATIENT CONCERNS

We report a case of a 66-year-old woman with these 2 coronary abnormalities accompanied with a huge mediastinum mass.

INTERVENTIONS

The giant aneurysm was ligated and the mass was resected which was proved to be an organized hematoma finally.

OUTCOMES

The patient was discharged soon with no complications.

LESSONS

The best treatment of giant coronary aneurysm is not clear because of its rarity, surgical resection may be the right procedure for the potential serious complications like this case.

Fused cardiac hybrid imaging with coronary computed tomography angiography and positron emission tomography in patients with complex coronary artery anomalies

OBJECTIVE

To provide data on the value of fused cardiac hybrid imaging with coronary computed tomography angiography (CCTA) and positron emission tomography myocardial perfusion imaging (PET-MPI) in patients with complex coronary artery anomalies (CCAA).

DESIGN/SETTING

This is a retrospective, single-center study.

PATIENTS

Seven consecutive patients with CCAA (mean 57 ± 7 y, 86% were male) who underwent clinically indicated hybrid CCTA/PET-MPI between 2005 and 2015 in our clinic were included. The findings from both modalities and fused cardiac hybrid imaging were evaluated in these patients.

RESULTS

Out of the seven patients with CCAA, two patients had Bland-White-Garland anomaly, two patients showed a coronary artery fistula, two patients showed a "single right," and one patient showed a "single left" coronary artery. Semiquantitative fused hybrid CCTA/PET-MPI depicted inferolateral scar matching the territory of a nonanomalous vessel with significant concomitant coronary artery disease (CAD) in one patient only. In contrast, analysis of quantitative myocardial blood flow (MBF) as assessed by fused hybrid CCTA/PET-MPI revealed abnormally reduced flow capacities in the territories subtended by the anomalous vessels in 4 patients.

CONCLUSIONS

In this case series of middle-aged patients with CCAA, perfusion defects as assessed by semiquantitative PET-MPI were rare and attributable to concomitant CAD rather than to the anomalous vessel itself. By contrast, impaired MBF as assessed by quantitative hybrid CCTA/PET-MPI was revealed in the majority of patients in the vessel territories subtended by the anomalous coronary artery itself. Fused hybrid CCTA/PET-MPI incorporating information on morphology and on semiquantitative and quantitative myocardial perfusions may provide added value for the management of patients with CCAA.

Use of an Amplatz Canine Ductal Occluder (ACDO) device to close an acquired aortopulmonary fistula with a hybrid approach in a dog

A 2-year-old recently spayed female Rottweiler was referred as an emergency with cardiac tamponade and the presence of an anomalous retrograde flow in the pulmonary artery. Echocardiography and angiography demonstrated a left-to-right aortopulmonary fistula. Clinical history and data indicated a possible infectious aetiology. Antibiotics and heart failure medications were administered for 30 days before intervention. Initial attempt at insertion of an Amplatz occluder by means of a percutaneous catheterization technique was tried but a safe release of the device was judged to be not possible due to the angle and the fragile and irregular margins of the window. A decision was made to proceed with a hybrid technique combining thoracotomy and direct pulmonary artery catheterization. This hybrid approach was successful with resolution of congestive heart failure with only residual mild paraprosthetic leakage.

Left main coronary artery fistula to superior vena cava

Coronary artery fistula (CAF) is an uncommon vascular malformation. As the majority of patients remain asymptomatic, approximately half of the cases may be clinical undetectable. We report here a rare case of a 10-year-old female with CAF from the left main coronary artery to the superior vena cava detected on echocardiography and CT angiography.

Idiopathic Atrial Fibrillation and Coronary Arteriovenous Fistulae: Is There a Link?

Despite being one of the most prevalent cardiac arrhythmias, the cause of atrial fibrillation (AF) in a vast majority of patients remains unknown. There is growing evidence of associated AF in patients diagnosed with coronary arteriovenous fistula. In this discussion, we have included an example of a patient who presented with new-onset AF and was subsequently diagnosed with an anomalous fistula between the right coronary artery and the superior vena cava. Definitive treatment of the fistula resulted in permanent resolution of the AF. Based on this case and a similar case reported in the literature, it is proposed that further research will unmask this possibly underdiagnosed and very treatable cause of AF.

Congenital Giant Right Coronary Artery to Pulmonary Artery Fistula and Congenital Left Main Coronary Artery Atresia: A Case Report

Both of congenital giant RCA, RCA to PA fistula, and CLMCA-A are one of exceedingly rare vascular abnormalities. We present the case of a 34-year-old man with multiple congenital coronary anomalies above, and a successful surgical intervention was proceeded for our patient.This is a case of a 34-year-old man presented with apical systolic murmur and exertional chest pain. Furthermore, a dilated left heart and abnormal pulmonary blood flow was observed in this patient. Coronary CTA and selective CAG showed a 15-mm diameter RCA with a fistula to pulmonary trunk and CLMCA-A. During cardiac surgery, the coronary abnormalities were confirmed and the outlet of the fistula was closed. After surgery, less chest pain, respiratory infection, and left heart failure were observed in this patient.This case illustrates that the surgery of closing the fistula between the giant RCA and pulmonary trunk could improve the symptoms and signs for this patient. It could be predicted that simplified operation could be a promising therapy for patient with giant RCA to PA fistula and CLMCA-A. Moreover, CABG should be taken full account of when myocardial ischemia was found in the blood-supply area of LAD.