Transcatheter coil embolization of a fistula from the posterior descending coronary artery to the right ventricle in a two-year-old child

Huge aneurysm and coronary-cameral fistula from right coronary branch: First case

Coronary-cameral fistulas are rare cardiovascular anomalies. A giant coronary artery aneurysm associated with a coronary-cameral fistula is a very rare condition, with an estimated prevalence of 0.02%. We report the case of middle-aged woman who presented with a huge extracardiac aneurysmal mass and a coronary-cameral fistula from a right coronary artery branch. It was successfully repaired by ligation and excision plus marsupialization of the aneurysm. We believe this is the first such a case reported in literature.

Gender-related differences in octogenarians with congenital coronary artery fistula: a report of two cases and a review

AIM

To highlight gender-related differences in octogenarians with a congenital coronary artery fistula (CAF).

MATERIALS AND METHODS

We present two elderly female patients with a congenital fistula, a septuagenarian and a nonagenarian, and review the world literature between 1954-2010.

RESULTS

The septuagenarian patient presented with easy fatigability and the nonagenarian patient with acute myocardial infarction contralaterally to the fistula. Coronary angiography (CAG) demonstrated a coronary-pulmonary artery fistula (CPF). The nonagenarian patient underwent percutaneous coronary intervention of the right coronary artery. CAG revealed a CPF associated with a huge multiple aneurysmal formation. Data from 57 mainly symptomatic patients with a mean age of 75.3 years (range 70-87 years) were collected. The cohort was subdivided into female (mean age 84.3 years) and male (mean age 75.2 years) subgroups and compared with each other. Multi-origin (bilateral and multilateral) was prevalent in females, 40% versus 12% in males. Aneurysmal formation was found in females and males in 40% and 18%, respectively. Ethnicity was 65% Caucasian and 35% Asian. Multi-origin fistulas were prevalent in the Asian (45%) compared with the Caucasian (11%) subset.

CONCLUSIONS

A septuagenarian and a nonagenarian female patient with congenital CAF are presented. On reviewing the literature, important differences were found between elderly females and males with congenital CAF.

Diagnosis and management of congenital coronary arteriovenous fistula in the pediatric patients presenting congestive heart failure and myocardial ischemia

PURPOSE

Four pediatric patients with congenital coronary arteriovenous fistula (CAVF) were reported to remind pediatric practitioners and cardiologists of its diagnosis and management.

MATERIALS AND METHODS

Four pediatric patients with congenital CAVF from June 1999 to November 2007 were included in this retrospective study. Study modalities included reviews of patients' profiles of clinical features, chest radiograph, Doppler echocardiography, cardiac catheterization with angiography, myocardial perfusion scan, and computed tomography.

RESULTS

All 4 patients were symptomatic. The clinical symptoms and signs were feeding problem, continuous murmur, tachycardia, tachypnea, cardiomegaly, and exertional chest pain. Myocardial enzyme was elevated in 1 patient. Echocardiography showed dilatation of the coronary artery in all 4 patients, and traced down its origin in 3 and drainage in 4. The fistulas originated from the right coronary artery in 2 patients and left coronary artery in 2, and were drained into the right ventricle in 2, right atrium in 1, and pulmonary artery in 1. Single left coronary artery was found in 1 patient. The pulmonary-to-systemic blood flow ratios ranged from 1.2 to 2.5. Transcatheter coil occlusion was successfully performed in 4 patients through a coaxial delivery system. The symptoms and signs of congestive heart failure and myocardial ischemia disappeared after the procedure.

CONCLUSION

Diagnosis of congenital CAVF could be achieved by appreciation of continuous murmur over area unusual for the ductus, and by scrupulous examination of echocardiography as well as angiography of the coronary artery through which coaxial transcatheter coil occlusion could be performed successfully.

Surgical outcome of coronary artery fistulas repair in children

Coronary artery fistula (CAF) is a rare congenital anomaly that can be complicated by endocarditis, myocardial infarction, or coronary aneurysms. This article reviews the clinical characteristics and surgical outcome of 10 patients with CAF in Rajae Heart Center. From 1990 to 2000, 10 patients (age, 6 months to 15 years; mean age, 8.5 years) were diagnosed with CAF by echocardiography and cardiac catheterization. Six were female and 4 were male. All patients with isolated CAF (9) were asymptomatic. One patient with associated anomaly (mitral valve prolapse with severe mitral regurgitation) had dyspnea on exertion and palpitation. Five fistulas originated from the right coronary artery-three from the left and two from the left circumflex. Drainage was to the right ventricle (7), right atrium (2), and pulmonary artery (1). The ratio of pulmonary to systemic flow ranged between 1 and 1.6. All patients had surgical ligation. In the symptomatic patient, in addition to ligation, mitral valve replacement was performed. There was no operative or late death. Follow-up evaluation (range, 1-6 years; mean, 4.2 years) showed no evidence of recurrent or residual CAF. Surgical management of CAF is a safe and effective treatment resulting in 100% survival and clousure rate.

Successful Repair of a Rare Angiographic Presentation of Coronary Artery–Coronary Sinus Fistula

We report a rare case of right coronary artery-coronary sinus fistula successfully closed through coronary sinus in the second operation following identification of distal branches of the coronary artery. At nine months follow-up, patient is asymptomatic with no recurrence of cardiac murmur. Repeat coronary angiography at one year showed no connection between right coronary artery and coronary sinus. This case report highlights the difficulties in angiographic techniques, identification and interpretation of anatomy of these rare malformations. It also demonstrates the hazards of simple ligation of these anomalous vessels without first understanding the anatomy of the regional coronary circulation. A brief review of literature on coronary artery fistula will be presented.

Techniques and applications of transcatheter embolization procedures in pediatric cardiology

Transcatheter embolization of congenital or acquired superfluous vascular structure has become routine procedures performed by interventional pediatric cardiologists. Embolization procedure is often part of a collaborative effort with cardiac surgeons to palliate complex congenital heart defect, such as in embolizing aortopulmonary collateral arteries in patient with single ventricle physiology. In other cases, the procedure is the definitive treatment as in embolizing coronary artery fistula. Pediatric cardiologists performing embolization procedures should be familiar with available technologies as well as understand the underlying cardiac anatomy and pathophysiology. This article provides a comprehensive review of presently available embolization agents and technologies. Some of the technologies are used only by interventional radiologists but may be useful to pediatric cardiologists. Specific clinical applications in pediatric cardiology are also discussed with summary of current literature. With continue advancement in transcatheter technology and operator expertise, all unwanted vascular communication should be amenable to transcatheter embolization.

Successful transcatheter coil embolization of coronary artery fistula in an infant

Congenital coronary artery fistula is a rare anomaly that can cause several types of morbidity as well as mortality. Recently, transcatheter coil embolization for congenital coronary artery fistula has been advocated as an effective alternative to surgical repair and is associated with a low morbidity and good clinical outcome. We report a 49-day-old infant who had tachycardia, tachypnea, prolonged and interrupted feeding, cardiomegaly, and continuous murmur, and who underwent successful transcatheter coil embolization for a congenital right coronary artery fistula. At review 1 year after coil occlusion showed that serial plain chest radiographs, myocardial enzyme analysis, electrocardiography, and wall motion on echocardiography were normal.

Embolization therapy in pediatric cardiology

Transcatheter embolization therapy has assumed an important role in the management of patients with congenital heart disease. A variety of embolization materials, most commonly steel coils, is available to treat or palliate patients with aortopulmonary collateral vessels or surgical shunts, arteriovenous malformations, and anomalous venovenous connections (common after surgical intervention for the univentricular heart). At many centers, coil occlusion has recently become the treatment of choice for patients with a restrictive patent ductus arteriosus (PDA). This article describes the materials and techniques of embolization therapy, as well as the common indications encountered in the practice of pediatric interventional cardiology.

Coronary artery fistula in the pediatric age group: a 19-year institutional experience

Ten patients with coronary artery fistulae were identified from records at Columbus Children's Hospital between 1974 and 1993. Clinical presentations of patients were quite variable, from 1 day to 20 years of age. Symptoms ranged from none to severe cardiorespiratory failure requiring extracorporeal membrane oxygenation. Long term follow-up revealed one sudden death and one spontaneous closure of the fistula. This lesion should be ruled out in patients who present as extracorporeal membrane oxygenation candidates. Patients with mild forms of this lesion may be followed up medically if the left to right shunt is inconsequential, because spontaneous closure is a possibility. Because of the risk of sudden death, close long-term follow-up is mandatory even for operated patients, and antiplatelet therapy should be considered for these patients.