Closure of a coronary cameral fistula following endomyocardial biopsies in a cardiac transplant patient with a detachable balloon

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.

Coronary-cameral fistulas in adults: Acquired types (second of two parts)

Acquired coronary artery fistulas (CCFs) are infrequently detected during conventional coronary angiography. To delineate the characteristics of congenital (first part) and acquired (second part) CCFs in adults, a PubMed search was conducted for papers dealing with congenital or acquired CCFs. None of the publications describing patients with coronary-vascular fistulas were included. Papers dealing with pediatric subjects were excluded. From the world literature, a total of 243 adult patients were selected who had congenital (n = 159/243, 65%) and acquired (n = 84/243, 35%) CCFs. Among the acquired types (n = 72, 85.7%) were traumatic (iatrogenic (n = 65/72, 90%), accidental (n = 7/72, 10%) and (n = 12, 14.3%) spontaneously developing in relation to severe coronary atherosclerosis or myocardial infarction. A high incidence of spontaneous resolution of iatrogenic CCFs resulting from endomyocardial biopsy or following post-septal myectomy was reported. Spontaneous CCFs associated with myocardial ischemia or infarction resolved completely in 8% of the subjects. Early surgical intervention was the treatment of choice in acquired traumatic accidental CCFs. The congenital types are addressed in a previous issue of this journal (first part). In this review (second of two parts, part II), we describe the acquired coronary-cameral fistulas.

Transcatheter closure of coronary artery fistula using Guglielmi detachable coil

Background

Coronary artery fistula (CAF) is a rare anomaly. Transcatheter CAF closure has been introduced using various materials, but only few data are available on the Guglielmi detachable coil (GDC). The advantage of using GDC for transcatheter CAF closure is more controllable, therefore much safer when compared to other coils. This report is about our experience in transcatheter closure of CAF using fibered GDC in our hospital.

Methods & Results

From 2002 to 2007, there were 10 patients with CAFs (age range: 28 to 56 year-old, 7 males) who underwent transcatheter CAF closure. There were a total of 19 CAFs which originated from right coronary (n = 5), left circumflex (n = 3), left anterior descending artery (n = 10) and left main trunk (n = 1). Median number of coil deployment for each fistula was 3 (range: 1 to 6). The pulmonary artery was the most common site of the distal communication of CAFs (n = 14), followed by right atrium (n = 3), left atrium (n = 1) and left ventricle (n = 1). Immediate coronary angiography after GDC deployment revealed no residual shunt in 12 (63.2%) CAFs, significant reduction of the flow in 5 (26.3%), while 2 (10.5%) could not be closed due to small size. Nine (90%) patients underwent a repeated angiography within 3 to 8 months. Among 12 CAFs that were occluded immediately post-deployment, there were 2 CAFs with insignificant residual flow. Among 6 CAFs with significantly decreased flow immediately post-deployment, 2 were occluded totally in the follow-up angiography. In total, 12 (70.5%) CAFs were occluded completely and 5 (29.5%) CAFs still had insignificant residual flow, which did not need any additional coil deployment. During a mean follow up of 4.3 ± 0.7 year, all patients remained symptom and complication free.

Conclusions

The fibered GDC is a safe and effective method for percutaneous closure of the CAFs.

Surgical treatment of coronary-to-pulmonary fistula: how and when?

Coronary arteriovenous fistulas (CAVF) are rare malformations. Opinions vary on which operation should be offered to these patients, particularly those asymptomatic. We report four patients operated on for CAVF referred to our institution over the course of a year. Three patients had associated cardiac lesions. In all of them CAVF was identified and closed with running sutures. There was no operative mortality or operative morbidity. All patients were asymptomatic at follow-up. In patients undergoing surgical treatment of cardiac disease, associated CAVF should always be treated. Although in patients with giant CAVF it is safer to patch the outflow of CAVF from the outflow chamber, in the majority of cases CAVF should be identified intraoperatively and closed with multiple running stitches.

Cardiac transplantation complicated by acute thrombotic occlusion of the right coronary artery

We report the case of a 63-year-old male patient undergoing cardiac transplantation due to fourth time aortic valve endocarditis. The postoperative course was complicated by thrombotic occlusion of the right coronary artery (RCA) causing acute right ventricular myocardial infarction, which required extracorporeal membrane oxygenation. The RCA could be reopened by catheter-based intervention and the patient stabilized. In order to avoid further immobilization, a right ventricular assist device was implanted and an aortocoronary bypass to the RCA was performed. After that, the patient stabilized progressively, could be weaned from the assist device, and was discharged home 6 weeks after transplantation. On coronary angiography, which is routinely performed 4 to 6 weeks after transplantation, a fistula from the RCA to the right ventricle was detected which was treated conservatively. Five months after transplantation, the patient is in good clinical condition without signs of recurrent endocarditis. This case shows that intense interdisciplinary cooperation of cardiac specialists allows the successful management of very complex patients in serious clinical conditions.

Myocardial infarction after endomyocardial biopsy in a heart transplant patient

In a heart transplant patient who had undergone several endomyocardial biopsies, ultrasound examination revealed severe left ventricular dysfunction after a stroke. Coronary angiography showed a distal left anterior descending artery fistula to the right ventricle. Left ventricular angiogram showed apical dyskinesia. The electrocardiogram and angiographic changes were thought to be due to a myocardial infarction secondary to a postendomyocardial biopsy hematoma, which should be added to the list of possible complications involved in endomyocardial biopsy.

Traumatic coronary artery fistula management

Traumatic coronary artery-cameral fistulas (TCAF) are uncommon sequelae of trauma that require early surgical intervention to prevent complications. The etiology of traumatic coronary artery-cameral fistulas may be classified as accidental or iatrogenic and have distinctly different courses depending on the etiology. The two operations described for definitive surgical closure of a traumatic coronary-cameral fistula are external ligation/obliteration of the fistula (with or without bypass grafting to the coronary artery distal to the fistula) and direct repair of the fistula from within the recipient chamber. The technique of fistula closure from within the recipient chamber is associated with a reduced incidence of fistula recurrence. A case report and a collective literature review are presented.

Segmental degradation of left ventricular wall motion after persistent coronary fistula in a posttransplantation patient: a case report and short review of literature

A 50-year-old man received an orthotopic heart transplant because of severe coronary heart disease and congestive heart failure. Two years after the transplantation, a continuous murmur occurred at the left sternal edge after repeated endomyocardial biopsies. Echocardiography and coronary angiography revealed a dilated left anterior descending artery with a fistula to the right ventricle. The circumflex was large with an equally postero-lateral branch, and the right coronary artery was rather small with collaterals to the distal part of the left anterior descending branch. The patient had refused any intervention to close the fistula. The left ventricular levogram was normal. Two years later, in a follow-up angiogram, the left ventricular ejection fraction had decreased as a result of hypo- and akinesis of the apex and posterior wall. We suggest that this local wall motion disturbance derives from a steal phenomenon rather than being a sequela of rejection. The decrease in left ventricular ejection fraction was associated with shortness of breath upon moderate exercise. Standard heart failure medication relieved the patient's symptoms. The observation of local wall motion disturbances in this case, as well as conflicting views in the literature, raises the question whether postbiopsy coronary fistulas in transplant patients should be closed.

Coronary artery fistulas in infants and children: a surgical review and discussion of coil embolization

BACKGROUND

Coronary artery fistula (CAF) is a rare congenital anomaly that can be complicated by intracardiac shunts, endocarditis, myocardial infarction, or coronary aneurysms. Recent reports have emphasized the efficacy of percutaneous transcatheter techniques. The purpose of this article is to review a 28-year surgical experience with CAF as a standard for comparison and to discuss the emergence and efficacy of transcutaneous catheter coil embolization as an alternative form of therapy.

METHODS

From 1968 to 1996, 17 patients (age, 6 weeks to 16.5 years; mean age, 5.5 years) were diagnosed with CAF: 8 of 12 by echocardiography and 17 of 17 by cardiac catheterization. All patients with isolated CAF (n = 13) were asymptomatic despite significant clinical, electrocardiographic, and chest roentgenographic findings in 10. Sixteen had congenital CAF and 1 had acquired CAF after tetralogy of Fallot repair with injury of the anomalous left anterior descending coronary artery. Associated anomalies included tetralogy of Fallot (2), atrial septal defect (1), and patent ductus arteriosus (1). Nine fistulas originated from the right coronary artery and eight from the left. Drainage was to the right ventricle (9), right atrium (4), pulmonary artery (3), and left atrium (1).

RESULTS

All patients had a median sternotomy with epicardial or endocardial ligation. Cardiopulmonary bypass was used in 8; 1 of these (iatrogenic CAF) required distal internal mammary artery bypass graft. There were no operative or late deaths. Follow-up evaluation by physical examination (17), echocardiography (8), and catheterization (2) showed no evidence of recurrent or residual CAF. A retrospective review of the 16 available cine cardioangiograms showed that coil embolization was possible in, at most, 6 patients.

CONCLUSIONS

Early surgical management of CAF is a safe and effective treatment resulting in 100% survival and 100% closure rate. Transcatheter embolization is a reasonable alternative to standard surgical closure in only a very small, select group of patients. These surgical results should be considered the standard against which transcatheter techniques are compared.

Coronary artery fistula after heart transplantation: a disappearing entity?

A high incidence of coronary artery fistulas has been observed angiographically after heart transplantation. To determine the present incidence of this finding and the natural history of fistulas in this setting, we reviewed coronary angiograms and clinical course on all patients (n = 480) transplanted from 1980 to 1990 who survived until the first annual coronary angiogram and compared the incidence of coronary artery fistulas in the early (patients #1-160), middle (patients #161-320), and late transplant (patients #321-480) groups. The 3-yr coronary artery fistula incidence for the early group was 3.5%, 6.9% for the middle group, and 2.9% in the late group (P < 0.05, early vs late). Patients who developed fistulas were followed longitudinally. Angiographic follow-up data (median duration: 6 yr) were available in 14 patients having 17 fistulas. No fistula increased in size, and in 10 of 14 patients (71%), fistulas became angiographically undetectable. No patient had any clinical complication related to the fistula. In summary, the incidence of coronary artery fistulas is presently lower than previously reported, which may in turn be related to refinements in heart biopsy technique. The lack of long-term clinical sequelae and the relatively high rate of disappearance favor a conservative approach of "watchful waiting."