Coronary artery to the left atrial fistula after resection of atrial appendages

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.

Quantitative Evaluation of the Substantially Variable Morphology and Function of the Left Atrial Appendage and Its Relation with Adjacent Structures

Objective

To investigate quantitatively the morphology, anatomy and function of the left atrial appendage (LAA) and its relation with adjacent structures.

Materials and Methods

A total of 860 patients (533 men, 62.0%, age 55.9±10.4 year) who had cardiac multidetector computed tomography angiography from May to October 2012 were enrolled for analysis.

Results

Seven types and 6 subtypes of LAA morphology were found with Type 2 being the most prevalent. Type 5 was more significantly (P<0.05) present in women (8.0%) than in men (4.2%). LAA orifice was oval in 81.5%, triangular in 7.3%, semicircular in 4%, water drop-like in 3.2%, round in 2.4% and foot-like in 1.6%. The LAA orifice had a significantly greater (P<0.01) major axis in men (24.79±3.81) than in women (22.68±4.07). The LAA orifice long axis was significantly (P<0.05) positively correlated with the height, weight and surface area of the patient. The LAA morphology parameters displayed strong positive correlation with the left atrium volume, aortic cross area long axis or LSPV long axis but poor correlation with the height, weight, surface area and vertebral body height of the patients. Four types of LAA ridge were identified: AI, AII, B and C with the distribution of 17.6%, 69.9%, 5.9% and 6.6%, respectively. The LAA had a significantly (P<0.05) greater distance from its orifice to the mitral ring in women than in men. The LAA had two filling and two emptying processes with the greatest volume at 45% phase but the least volume at 5% phase. The LAA maximal, minimal and emptying volumes were all significantly (P<0.05) positively correlated with the body height, weight and surface area, whereas the LAA ejection fraction had an inverse correlation with the LAA minimal volume but no correlation with the maximal volume.

Conclusion

The LAA has substantially variable morphologies and relation with the adjacent structures, which may be helpful in guiding the LAA trans-catheter occlusion or catheter ablation procedures.

Circumflex coronary artery to left atrium fistula caused by mitral isthmus ablation

Mitral isthmus ablation is an important component of catheter ablation for persistent atrial fibrillation and mitral isthmus dependent flutters. We describe a case where mitral isthmus ablation caused a fistula between the left circumflex artery and the left atrium and symptomatic ischaemia. The fistula was successfully closed with a covered stent.

Prevalence of coronary artery fistulae after cardiac surgery. Comparison between coronary artery bypass grafting, valve surgery, and orthotopic heart transplantation

INTRODUCTION

Coronary artery fistulae (CAF) are anomalous connections from a coronary artery to a recipient pulmonary vessel or cardiac chamber, and are reported in 0.2 % of the general population. The prevalence of CAF in the modern orthotopic heart transplant (OHT) population has been demonstrated to be significantly higher. The mechanism is unknown but one proposal is endothelial and vascular growth factor activation from injury. We hypothesize an incremental increase in CAF prevalence with the complexity of surgery, such that patients who have undergone OHT surgery would have an increased prevalence of CAF, as compared with patients who have undergone coronary artery bypass (CABG) surgery with valve surgery and as compared with patients who have undergone CABG surgery only.

PATIENTS AND METHODS

Consecutive angiograms of 481 patients after CABG surgery and 432 patients after OHT were reviewed. Patients who had previous valve surgery in addition to CABG were identified. Presence of CAF was determined. The chi-squared test was used for statistical analysis.

RESULTS

In all, 436 patients had CABG only (group A), 45 patients had CABG with valve surgery (group B), and 432 patients had OHT (group C). The mean age of patients at the time of surgery for group A, B, and C was 59.0, 66.1, and 55.3 years, respectively. The percentage of male patients was 78.4, 77.8, and 77.1 %, respectively. We found 10 patients (2.3 %) with CAF in group A compared with 4 patients (8.9 %) in group B, and 88 patients (20.4 %) in group C, which was statistically significant (p < 0.001). All CAF were small, were not associated with hemodynamic compromise or significant adverse events, and were managed conservatively.

CONCLUSION

There is an increased prevalence of CAF formation both after CABG and OHT compared with the general population. The higher prevalence of CAF in patients who additionally underwent valve surgery or who underwent OHT may be attributed to differences in surgical complexity. The increased prevalence of CAF formation after OHT compared with CABG should be further investigated.

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.

A case of coronary artery fistula between a coronary artery and the left atrium following maze procedure

The authors report a case of a coronary artery fistula (CAF) after mitral valvuloplasty and a maze procedure. A 73-year-old man was admitted to the hospital with congestive heart failure. He had undergone mitral valvuloplasty and a maze procedure 10 years previously. An abnormal Doppler flow signal in the left atrium was incidentally found on transthoracic echocardiography. It was diagnosed as a CAF on transesophageal echocardiography and other imaging modalities. The detection of the abnormal flow just after the operation suggested a causal relationship between this fistula and the preceding surgical procedure. Acquired CAF following cardiac surgery is a rare abnormality. However, if abnormal flow is found on transthoracic echocardiography after cardiac surgery, this abnormality should be kept in mind.