Coronary artery fistulas: long-term results of surgical correction

Management of a Rare Case of Multiple Coronary Artery Fistulas Associated with Ascending Aortic and Root Aneurysm: Case Report and Review of Literature

Coronary artery fistulas draining into the left ventricle is a rare finding. They can be associated with other congenital cardiac anomalies like ventricular septal defect or tetralogy of Fallot. While most of them are asymptomatic, they can lead to severe cardiac complications like infective endocarditis, heart failure, or myocardial ischemia. Symptomatic coronary artery fistulas can be managed surgically or percutaneously. We present a case of a 61-year-old male patient with both left anterior descending artery and right coronary artery fistulas draining into the left ventricle associated with ascending aorta and root aneurysm. Preoperative assessment for myocardial ischemia and the size and location of the fistulas was performed. The echocardiography stress test was negative. Surgery consisted of replacement of the ascending aorta and reconstruction of the noncoronary sinus with a Dacron patch with aortic valve preservation and no intervention for the coronary artery fistulas. The surgical strategy was adapted for cardioplegia administration to compensate for the volume of coronary blood drained into the left ventricle and for better protection of the distal myocardium.

Coils embolization use for coronary procedures: Basics, indications, and techniques

The use of coils is fundamental in interventional cardiology and can be lifesaving in selected settings. Coils are classified by their materials into bare metal, fiber coated, and hydrogel coated, or by the deliverability method into, pushable or detachable coils. Coils are delivered through microcatheters and the choice of coil size is important to ensure compatibility with the inner diameter of the delivery catheter, firstly to be able to deliver and secondly to prevent the coil from being stuck and damaged. Clinically, coils are used in either acute or in elective setting. The most important acute indication is typically the sealing coronary perforation. In the elective settings, coils can be used for the treatment of certain congenital cardiac abnormalities, aneurysms, fistulas or in the treatment of arterial side branch steal syndrome after CABG. Coils must always be delivered under fluoroscopy guidance. There are some associated complications with coils that can be acute or chronic, that nictitates regular followed-up. There is a need for education, training and regular workshops with hands-on to build the experience to use coils in situations that are infrequently encountered.

Coronary steal: how many thieves are out there?

The colorful term "coronary steal" arose in 1967 to parallel "subclavian steal" coined in an anonymous 1961 editorial. In both instances, the word "steal" described flow reversal in the setting of an interconnected but abnormal vascular network-in one case a left subclavian stenosis proximal to the origin of the vertebral artery and in the other case a coronary fistula. Over time, the term has morphed to include a larger set of pathophysiology without explicit flow reversal but rather with a decrease in stress flow due to other mechanisms. This review aims to shed light on this phenomenon from a clinical and a pathophysiological perspective, detailing the anatomical and physiological conditions that allow so-called steal to appear and offering treatment options for six distinct scenarios.

Coronary artery fistula with or without aneurysm: A large comparative study

Background

The knowledge of coronary artery fistula (CAF) with coronary aneurysm mostly comes from case reports and is very limited. However, the management of CAF with and without aneurysm is different, more understanding of its clinical and imaging features is necessary. This is the first research focus on it through a large comparative study.

Purpose

To investigate the differences in imaging and clinical features of CAF with and without aneurysms.

Methods

We reviewed 96,037 consecutive patients undergoing coronary computed tomography angiogram (CCTA) between 2016 and 2020 and total of 429 CAF adult patients were enrolled. Those patients were divided into the CAF with aneurysm group (321 cases, 74.83%) and CAF without aneurysm group (108 cases, 25.17%) according to whether complicated with coronary aneurysm. Clinical baseline data, electrocardiographic (ECG) characteristics, the presence or absence of coronary atherosclerosis, complication symptoms and fistulous origin, entry site, number and diameter were analyzed. Chi-square test, T-test, Mann-Whitney U tests, and logistic regression analysis were performed.

Results

Most of the clinical baseline data did not differ significantly between the two groups (P > 0.05). However, heart murmur, coronary atherosclerosis, infective endocarditis (IE), fistulous diameter and fistulous entry site were significantly different (P＜0.05). Further multivariate logistic regression analysis showed that large fistulous diameter and coronary-cardiac chamber arterial fistulas was dependent risk factors for CAF complicated with aneurysm.

Conclusion

CAF patients with aneurysm were more prone to develop heart murmur than those patients without aneurysm. Different from other sites of aneurysms, coronary atherosclerosis is more common in CAF without aneurysm. Larger fistulous diameter and coronary-cardiac chamber arterial fistula are dependent risk factors for CAF with aneurysms.

Long-Term Follow-Up of a Nonprogressive Left Main Coronary Artery Fistula to Right Atrium

Coronary artery fistula is a rare cardiac abnormality, occurring more frequently in young patients and treated with cardiac surgery or percutaneous interventions in most cases. We present the case of a 63-year-old man with an incidental diagnosis of coronary artery fistula, treated with conservative strategy. (Level of Difficulty: Intermediate.).

Surgery for Aneurysmal Coronary Artery Fistulas to the Coronary Sinus in Adults

Surgical treatment of aneurysmal distal congenital coronary artery fistulas depends on size and anatomy. From 2008 to 2021, we applied a new surgical technique in 7 adult patients: proximal and distal fistula closure, opening of aneurysmal artery, and revascularization of branches rising from the fistula under cardiopulmonary bypass and cardiac arrest. (Level of Difficulty: Intermediate.)

CTA analysis of 482 cases of coronary artery fistula: A large-scale imaging study

OBJECTIVE

The prevalence of coronary artery fistula (CAF) based on coronary angiography has been reported. However, with the popularity of coronary computerized tomography angiography (CTA), CAFs have been found more and more by chance. The purpose of this study was to determine the prevalence and types of CAFs detected by coronary CTA, and to explore the differences in the size of fistulas, the number of complicated aneurysms, and fistulas among different types.

MATERIALS AND METHODS

From January 2016 to December 2020, 96,037 patients underwent coronary CTA in our hospital. The prevalence of CAF was retrospectively evaluated, The origin, course, and drainage site of CAF and coexisting abnormalities were analysed. The conventional treatments and follow-up DSCT images were also evaluated. Analyze the difference between the coronary-pulmonary artery fistula (CPAFs) group (380) and the coronary-cameral fistula (CCF) group (99).

RESULTS

Among 96,037 patients, 482 (0.5%) patients (male 232 and 250 female) had CAF. The types of CAF detected. The pulmonary artery was the most common site of drainage (380/482, 78.8%). Of the 99 CCFs, coronary to the left ventricle is the most common pattern in CCF (34/482, 7.0%). Single origins are more common in CAF (n = 361, 74.9%), multiple origins are more common in CPAFs than in CCF. There were statistically significant differences in the stoma diameter (2.4 ± 1.1 mm vs. 5.4 ± 4.3 mm p < .05), aneurysm complicated (85 cases [85/380] vs. 50 cases [50/99]), the size of aneurysm (8.8 ± 5.7 mm vs. 19.1 ± 11.6 mm, p < .05), and single fistula (261 [261/380] vs. 96 [96/99], p < .05). Most of the 380 CPAFs patients received conservative treatment (350/380, 92.1%), While the 59 CCF patients (59/93, 63.4%) were treated.

CONCLUSIONS

Different from previous reports, the prevalence of CAF in coronary CTA is 0.5%, the incidence of CPAFs is the highest, and the incidence of the left ventricular fistula is higher in CCF. Compared with CPAFs, CCF fistulas were more likely to be associated with a larger diameter of draining, larger aneurysms, single fistula pattern. Coronary artery CTA is a useful and noninvasive imaging method to detect CAF, which is of great significance for the detection of small fistulas and the surgical guidance of complex CAF.

A rare cause of ischemic heart failure in a neonate

Herein, we present a case of ischemic heart failure that occurred immediately after birth in a neonate due to coronary artery fistula (CAF) from the left main coronary artery to the left atrial appendage associated with high pulmonary artery pressure. Ischemic heart failure in a neonate with a structurally normal heart is rare. Furthermore, CAF resulting in ischemic heart failure is very rare in neonates. We believe that the small CAF caused symptoms during the first few days of life due to moderate pulmonary hypertension which resulted in a low cardiac output. The coronary perfusion improved after the normalization of the pulmonary blood pressure and improvement of the cardiac output. Echocardiography is helpful when a CAF is suspected and can be confirmed using a cardiac computed tomography scan. Small CAFs are unlikely to cause symptoms in infants, provided there are no other factors affecting the cardiac output status.

Anatomical Classification and Posttreatment Remodeling Characteristics to Guide Management and Follow-Up of Neonates and Infants With Coronary Artery Fistula: A Multicenter Study From the Coronary Artery Fistula Registry

BACKGROUND

Coronary artery fistulas (CAFs) presenting in infancy are rare, and data regarding postclosure sequelae and follow-up are limited.

METHODS

A retrospective review of all the neonates and infants (<1 year) was conducted from the CAF registry for CAF treatment. The CAF type (proximal or distal), size, treatment method, and follow-up angiography were reviewed to assess outcomes and coronary remodeling.

RESULTS

Forty-eight patients were included from 20 centers. Of these, 30 were proximal and 18 had distal CAF; 39 were large, 7 medium, and 2 had small CAF. The median age and weight was 0.16 years (0.01-1) and 4.2 kg (1.7-10.6). Heart failure was noted in 28 of 48 (58%) patients. Transcatheter closure was performed in 24, surgical closure in 18, and 6 were observed medically. Procedural success was 92% and 94 % for transcatheter closure and surgical closure, respectively. Follow-up data were obtained in 34 of 48 (70%) at a median of 2.9 (0.1-18) years. Angiography to assess remodeling was available in 20 of 48 (41%). I. Optimal remodeling (n=10, 7 proximal and 3 distal CAF). II. Suboptimal remodeling (n=7) included (A) symptomatic coronary thrombosis (n=2, distal CAF), (B) asymptomatic coronary thrombosis (n=3, 1 proximal and 2 distal CAF), and (C) partial thrombosis with residual cul-de-sac (n=1, proximal CAF) and vessel irregularity with stenosis (n=1, distal CAF). Finally, (III) persistent coronary artery dilation (n=4). Antiplatelets and anticoagulation were used in 31 and 7 patients post-closure, respectively. Overall, 7 of 10 (70%) with proximal CAF had optimal remodeling, but 5 of 11 (45%) with distal CAF had suboptimal remodeling. Only 1 of 7 patients with suboptimal remodeling were on anticoagulation.

CONCLUSIONS

Neonates/infants with hemodynamically significant CAF can be treated by transcatheter or surgical closure with excellent procedural success. Patients with distal CAF are at higher risk for suboptimal remodeling. Postclosure anticoagulation and follow-up coronary anatomic evaluation are warranted.

Coronary Artery Fistulas: A Review of the Current and Future Roles of Imaging

Coronary artery fistulas are uncommon but clinically important entities that may produce symptoms and significant complications such as angina, myocardial infarction, coronary artery aneurysm formation, and congestive heart failure. Multiple fistula types have been recognized, and classification uses factors such as etiology, coronary artery origin, and drainage site. Both invasive and noninvasive imaging play an important role in the management and treatment of these patients, and often times, more than one modality is necessary for comprehensive evaluation of coronary fistulas. Recent advances in both functional and anatomic imaging will likely also play a growing role in fistula evaluation. The purpose of this article is to review the classification, pathophysiology, clinical presentations, imaging findings, treatment, and future imaging directions of coronary artery fistulas.

Long-term outcomes following surgical repair of coronary artery fistula in adults

BACKGROUND AND AIM OF THE STUDY

Coronary artery fistula (CAF) is a relatively rare cardiac anomaly. We investigated long-term outcomes following surgical repair of CAF in adults.

METHODS

We retrospectively investigated 13 consecutive patients undergoing surgical repair of CAF in our institution between 2008 and 2019 (67.3 ± 10.4 years old, 38% male). CAF types were coronary artery-pulmonary artery fistula (77%), coronary artery-coronary sinus fistula (15%), and both (8%). CAFs originated from the left coronary artery (38%), right coronary artery (8%), and bilateral coronary arteries (38%). Pulmonary and systemic flow (Qp/Qs) was measured in seven patients (54%), with a mean value of 1.52. Seven patients underwent surgery for CAFs alone, and others simultaneously underwent surgery for comorbid cardiac diseases.

RESULTS

All procedures were conducted under cardiopulmonary bypass. Surgical procedures were direct epicardial ligation of fistula (92%), direct closure of CAF through pulmonary artery incision (38%), direct closure of CAF through coronary sinus incision (8%), or patch closure of CAF through coronary artery incision (8%). Myocardial perfusion scintigraphy showed asymptomatic myocardial ischemia in the right coronary area after surgery in one patient. There were no deaths perioperatively or during follow-up (mean: 66.6 months). There were no coronary or other CAF-related events.

CONCLUSIONS

Several anatomical variations in CAF were observed which coexist with cardiac disease. Long-term outcomes following surgical repair were satisfactory, and the concurrent intervention of CAFs during surgery for comorbid cardiac disease is useful to prevent future complications related CAFs in adults.

Diverse Transcatheter Closure Strategies in Coronary Artery Fistulas A State-of-the-Art Approach

Coronary artery fistulas (CAFs) are accounted as the most congenital coronary anomalies. As their natural course is progressive dilatation of the feeder arteries and the fistula tract, so, catastrophic complications are frequently illustrated by aging. Even in those with asymptomatic small fistulas, close follow-up is mandatory to prevent subsequent sequelas. In patients with medium or large-sized fistulas, irrespective of symptoms, closure (either by surgical ligation or transcatheter closure) is recommended. In the current era of advances in the equipment and devices and also innovations in percutaneous closure techniques and preprocedural imaging, TCC is now regarded as the preferred strategy for CAF closure except in some high-risk cases. So, by appropriate case selection modalities, pre-procedural planning, and determining the closure techniques, recent small case-series studies have been reported good final angiographic and clinical results by TCC. In this article, we have introduced several transcatheter closure techniques by details; also, we have recommended more multi-center trials with long-term clinical follow-up to address the best treatment options in these patients.

Surgical repair of a right coronary aneurysm with a coronary artery fistula to the right atrium

A coronary artery fistula is a rare condition caused by abnormal coronary artery embryological development. Although most cases are asymptomatic, in some, the large shunt volume and the myocardial ischemia due to the steal phenomenon require surgical treatment. We present the case of a 40-year-old woman who presented with angina on exertion. Enhanced computed tomography showed a giant right coronary artery (RCA) aneurysm with an RCA-to-right atrium fistula. Because of the presence of symptoms and the presence of large fistulous tract, the patient was considered a surgical candidate. The procedure was performed under cardiopulmonary bypass. Ligation and closure of the fistula were performed in combination with dissection of the enlarged main trunk of the RCA and coronary artery bypass using the internal thoracic artery because of its potential for long-term patency. The postoperative course was uneventful.

Anomalous Coronary Arteries: When to Follow-up, Risk Stratify, and Plan Intervention

PURPOSE OF REVIEW

Coronary artery anomalies are a diverse group of entities, ranging from benign variations of normal anatomy to life-threatening conditions. There is, however, no universal consensus in their classification, risk stratification, and management. The aim of this review is to develop a straightforward clinical approach for the assessment and care of patients with anomalous coronary arteries.

RECENT FINDINGS

Autopsy series and population screening studies have recently provided useful clinical data on the prevalence and outcomes of coronary anomalies. Also, findings on coronary computed tomography angiography, magnetic resonance imaging, and invasive angiography, enriched with fractional flow reserve and intravascular ultrasound, have allowed identification of several high-risk features associated with specific coronary anomalies. Management of patients with anomalous coronary arteries requires an individualized approach based on clinical, physiological, and anatomic features. High-quality studies are paramount for further development of this fascinating field.

Myocardial ischemia due to radical resection of complex coronary fistulas with giant aneurysms: a case report

A 56-year-old man underwent surgery for complex coronary artery fistulas with giant coronary aneurysms. This treatment resulted in complications and caused myocardial ischemia of the right ventricular outflow tract, resulting in repeated ventricular fibrillations. The irritability caused by this fetal arrhythmia was improved by the placement of an intra-aortic balloon pump. The case findings suggest that even careful resection of complex coronary fistulas could precipitate myocardial ischemia.

Colossal left main to right atrium fistula ligation complicated by left circumflex STEMI

Congenital left main (LM) coronary artery to right atrium fistulas with progression to aneurysm development are rare. Most patients remain asymptomatic, but for those with progressive symptoms, intervention is required. However, there are potential life-threatening complications associated with surgical intervention. We present a case of an extremely rare markedly aneurysmal LM to right atrial fistula treated with surgical ligation complicated by inferolateral ST-elevation myocardial infarction several days post-operatively treated successfully using mechanical aspiration thrombectomy, a stent-retriever, balloon angioplasty, and subsequent intravascular ultrasound-guided percutaneous coronary intervention with drug-eluting stent.

Stolen from the coronaries: Left-to-Left shunts presenting as chest pain syndrome!

We present the case of a 61-year-old woman with chest pain syndrome. Cardiac catheterisation did not reveal atherosclerotic coronary disease. However, a haemodynamically significant fistula connecting the left coronary artery to the left atrial appendage was found to be the culprit through a left-to-left shunting mechanism. In this report, we review the pathophysiology of coronary artery fistulas and the mechanism by which these fistulas may lead to 'coronary steal syndrome'. Indications for interventional and surgical management are outlined. Ultimately, we suggest the consideration of coronary artery fistulas in the differential diagnosis of patients presenting with chest pain.

Complete closure of coronary fistula communicating with the descending aorta

We report a rare case of complex coronary fistula that contained two aneurysms and was connected to the descending aorta. The fistula was also associated with further aortic pathologies necessitating surgery. Preoperative computed tomography angiography, which revealed an abnormal vessel communication, was crucial for choosing the appropriate operative strategy. During a one-stage procedure comprising closure of both arterial (aortic and coronary) fistula origins and repair of the aortic valve and thoracic aorta, the coronary origin of the fistula was ligated and the frozen elephant trunk technique was used to close the aortic origin.

Coronary Steal in a Patient With Apical Hypertrophic Cardiomyopathy: A Rare Case of Symptomatic Coronary Artery Fistula

This report describes a rare case of multiple left coronary artery to pulmonary artery/left atrial fistulae causing a coronary steal phenomenon. A 58-year-old male with apical hypertrophic cardiomyopathy was seen in an outpatient office for exertional chest pain and dyspnea and subsequently had a positive exercise nuclear stress test. Coronary angiogram revealed 70-80% mid-left anterior descending artery stenosis with multiple proximal coronary artery to left atrial/pulmonary artery fistulae. Due to symptomatic coronary artery fistulae with coronary steal phenomenon, the patient underwent surgical correction of fistulae with bypass graft to left anterior descending artery. To our knowledge, this is the first case report on co-existing apical hypertrophic cardiomyopathy and coronary artery-left atrial/pulmonary artery fistulae. This article reviews current guidelines for management of coronary artery fistula.

Congenital coronary artery fistula in pediatric patients: transcatheter versus surgical closure

OBJECTIVES

Transcatheter closure (TCC) and surgical closure (SC) are the two main approaches for congenital coronary artery fistula (CCAF), but data on the comparisons of the efficacy and safety of these two approaches are limited.

METHODS

We retrospectively reviewed pediatric patients with CCAF in Guangdong Cardiovascular Institute between January 2002 and December 2017. Patients who were qualified into our criteria were included into final analysis. The rate of successful closure and complications during hospitalization and at follow-up were compared between SC and TCC groups.

RESULTS

In total, 121 pediatric patients (male, n = 69; female, n = 52) with CCAF were divided to TCC (n = 63) and SC groups (n = 58) according to the indications. The mean age was 5.3 ± 1.4 years. The baseline characteristics of these two groups were similar except for the fistula anatomic feature. After adjusted for the fistula anatomy, compared to SC, TCC was associated with higher risk of major complications (p = 0.013). Proportions of patients requiring blood transfusion and intra-operative blood loss were higher in SC versus TCC groups, as were longer duration of hospital and ICU stay during hospitalization. In contrast, myocardial ischemia (10.2% vs 0.0%, p = 0.028), residual shunts (16.9% vs 3.6%, p = 0.045) and new-onset moderate-to-severe valve regurgitation (11.9% vs 0.0%, p = 0.013) were higher in TCC group versus SC groups during follow-up.

CONCLUSIONS

TCC has less invasive and faster recovery. However, SC had a higher successful rate and lower risk of major complications in pediatric patients.

A case report of a coronary artery fistula to coronary sinus with giant aneurysm: risk does not end with repair

Background

Isolated coronary arteriovenous fistulas are extremely rare, accounting for 0.08–0.4% of all congenital heart disease. Closure of the fistula is recommended in cases of large dimensions, relevant left–right shunt, or ischaemic events. Thrombosis of the coronary aneurysms may occur as a postoperative complication.

Case summary

We report a case of a coronary fistula between the circumflex artery and coronary sinus with giant aneurysm. After a failed percutaneous closure attempt, the patient was surgically treated without major postoperative complications. Despite therapeutic anticoagulation and antiplatelet therapy, she presented at clinical follow-up with thrombosis of the dilated coronary artery without signs or symptoms of ischaemia.

Discussion

Management of coronary artery fistula may be challenging in cases in which initial percutaneous closure is unsuccessful. This particular case also highlights the importance of close follow-up, despite optimal therapy, to detect potentially lethal complications related to the low flow in the dilated coronary aneurysm.

Ruptured aneurysm of coronary arteriovenous fistula without aneurysmal coronary artery

BACKGROUND

Approximately 25% of coronary arteriovenous fistulas present aneurysmal dilatation; however, spontaneous rupture of the aneurysm is rare. Most coronary arteries branching the feeding arteries demonstrate aneurysmal formation, possibly because of shunt flow.

CASE REPORT

A 48-year-old woman was referred to our institution for surgical management of ruptured aneurysm of coronary arteriovenous fistula. The aneurysm was located on the left-anterior aspect of the pulmonary artery trunk, communicating with both left and right coronary arteries through two small feeding arteries draining into the pulmonary artery trunk. Both left and right coronary arteries showed normal diameter. The feeding arteries were ligated externally, and fistulous openings were closed within the aneurysm. Postoperative course was uneventful.

CONCLUSION

Aneurysm of coronary arteriovenous fistula can occur in patients without aneurysmal coronary artery. Although the association of ruptured aneurysm with coronary fistulas is relatively rare, it should be considered a potential cause of acute cardiac tamponade.

Coronary artery fistula in adults: Incidence and appearance on cardiac computed tomography and comparison of detectability and hemodynamic effects with those on transthoracic echocardiography

BACKGROUND

The widespread use of cardiac computed tomography (CT) has increased the incidental discovery of fistulas of the coronary artery (CAF). This condition is rare and can affect hemodynamic parameters, but few reports focus on its hemodynamic effects. We investigated the frequency and types of CAF on CT and compared them with those of transthoracic echocardiography (TTE) to evaluate the detectability of CAF and its hemodynamic effects.

MATERIALS AND METHODS

We retrospectively evaluated cardiac CT images of 6789 adult patients who underwent imaging from January 1, 2013 through September 30, 2019 at our institution. We assessed the CT images for the presence of CAF and compared our findings with those obtained by TTE in control cases without CAF.

RESULTS

The prevalence of CAF determined with cardiac CT was 0.91%, with the left anterior descending artery (67.7%) as the most common site of origin and the main pulmonary artery (82.3%) as the most common origin of drainage. The incidence of aneurysm accompanying CAF was 48.4%. Color Doppler in TTE demonstrated abnormal flow that would suggest the presence of CAF of only 23.1%. Echocardiographic findings of hemodynamics did not differ significantly between patients with and without CAF nor between elderly and non-elderly patients with CAF.

CONCLUSIONS

Our study revealed differing prevalence and types of CAF from those reported using coronary angiography and little impact of CAF on hemodynamics. Color Doppler in TTE did not readily depict abnormal flow that might suggest the presence of a fistula, but cardiac CT allowed noninvasive and comprehensive assessment of CAF. Thus, we believe the acquisition of cardiac CT is necessary to establish the cause of continuous murmur that is not identified with TTE.

Atypical Presentation of Coronary Artery Fistula: Case Report and Review of the Literature

Chest pain is one of the common complaints a patient presents to the healthcare provider. It needs prompt evaluation to determine the cause and origin. Angina occurs when myocardial oxygen demand exceeds oxygen supply; the clinical manifestation is often chest discomfort. Atherosclerotic disease is the major cause of angina. However, several non-atherosclerotic conditions have been studied and reported in the literature that causes angina in rarity. We describe a case of coronary artery fistula (CAF) likely causing angina.

Left anterior descending coronary artery compressed by a giant coronary fistula aneurysm: a case report

Background

Ischaemic chest pain can be originated by different causes. Among all, coronary fistulas are rarely the reason. Such entities are usually asymptomatic and can be diagnosed by echocardiography or coronary angiography. In an even rarer scenario, coronary fistulas might dilate and form an aneurysm.

Case summary

We report the case of a 62-year-old patient who was initially referred to the emergency department for stable angina. Coronary angiography and computed tomography scan showed a giant aneurysm relating to a coronary fistula with a course from the circumflex coronary artery to the superior vena cava. The aneurysm was critically compressing the left anterior descending coronary artery. It was confirmed and resolved by surgery.

Discussion

Giant aneurysms of a coronary fistula are very uncommon entities. We describe a rare case of angina caused by extrinsic compression of the left anterior descending artery from a giant aneurysm of a coronary fistula.

Transcatheter occlusion of giant congenital coronary cameral fistulae: a case series

BACKGROUND

A coronary cameral fistula is a rare connection between a coronary artery and a cardiac chamber or vein bypassing the cardiac capillary bed system. Most of these fistulae are congenital and solitary, although they can be acquired and multiple.

CASES PRESENTATION

Case 1: A 10-year-old black South African boy presented with a long-standing history of fatigue; he had a heart murmur, and a bounding pulse and wide pulse pressure. An echocardiogram demonstrated a large coronary cameral fistula involving his left coronary artery and his left ventricle. This was also confirmed on ascending aortogram. Surgical ligation was done and his symptoms improved afterward, but a small residual fistula remained. Case 2: A 7-year-old black South African boy had decreased effort tolerance and a heart murmur on the mid-sternal border. He had cardiomegaly on chest roentgenogram and a dilated left coronary artery origin on echocardiogram. An ascending aortogram confirmed a large left coronary cameral fistula draining to the left ventricle. Case 3: A 28-year-old black South African woman with decreased effort tolerance and chest pain on exertion had a continuous murmur over the lower sternal border. Echocardiography demonstrated a dilated right coronary artery with a fistulous connection to her right ventricle. An ascending aortogram demonstrated a tortuous coronary cameral fistula arising from her right coronary artery to her right ventricle. All three patients were successfully treated percutaneously using the Amplatzer vascular plug type II device.

CONCLUSION

The availability of numerous vascular closure devices has made transcatheter occlusion the treatment of choice for the majority of coronary cameral fistulae, rather than the traditional surgical ligation.

Successful surgical management for aneurysms of single coronary artery with a fistulous connection to the right ventricle

While a coronary artery fistula with aneurysmal formation is rare, a fistula/aneurysm combination occurring in single coronary artery is even rarer. Here, we report the successful surgical correction of a right ventricular fistula with a large aneurysm of 30 mm and a daughter aneurysm within a case of single coronary artery.

A Unique and Rare Presentation of Adult Congenital Heart Disease: Common Atrium Associated with Coronary Aneurysms and Fistula

An atrial septal defect is the second most common congenital heart disease found in adults with a female to male ratio of 4 : 1. However, it is rare to have a complete absence of the interatrial septum (IAS) to be diagnosed in an elderly patient associated with other coexisting anomalies. We present a case of a 60-year-old female presenting with common atrium, coronary arteriovenous fistula, and coronary artery aneurysms. This case highlights rare adult congenital cardiac anomalies and the importance of thorough workup to evaluate for the intracardiac shunt in a patient who has right heart enlargement and development of pulmonary disease in adulthood without a significant history of chronic smoking. A 60-year-old female patient presented with substernal chest pain. The nuclear stress test showed no reversible ischemia; however, right ventricle (RV) dilation was present. The patient underwent further evaluation for RV dilation with a transthoracic echocardiogram that demonstrated a complete absence of IAS and was confirmed by a positive bubble study. The patient had an invasive angiography that showed severely elevated RV pressure. Oxygen saturation in the right atrium was higher than in the inferior vena cava. Hence, an intracardiac shunt with a 10% increase in oxygen saturation was identified. It also identified aneurysmal coronary arteries (measuring 0.8 to 1.0 cm). Cardiac computed tomography angiogram was performed that identified all coronary arteries to be ectatic/aneurysmal measuring up to 8-10 mm, an absence of IAS, and a possible fistula between the distal left anterior descending and a coronary vein. To our knowledge, this is the first-ever presentation of a complete congenital absence of IAS in a patient who has survived into adulthood with the development of severe pulmonary hypertension without Eisenmenger syndrome. It is unclear at this point if surgical treatment to correct the anatomical defect (which would be probably palliative) would be superior to conservative medical therapy. Besides, the presence of coronary arteriovenous fistula would make the decision-making process more complex regarding surgical versus conservative management.

Coronary Arteriovenous Fistula Draining Into Persistent Left Superior Vena Cava

A 75-year-old woman was referred to our hospital for dyspnea and edema of the lower limbs. Computed tomography angiography revealed a dilated left coronary artery from the left main trunk to the left circumflex branch and a dilated fistula originating from the left circumflex branch and draining into the persistent left superior vena cava. Physical examination revealed pulmonary hypertension and congestive heart failure. We performed closure of the fistula and left main coronary artery orifice and coronary artery bypass grafting. Postoperative computed tomography angiography showed patency of all grafts and progression of thrombosis in the dilated abnormal vessels.

Coronary Arteriovenous Fistula in Continuity With the Aortic Arch

Coronary arteriovenous fistula in continuity with the aortic arch by abnormal vessels running along the surface of the pulmonary artery is rare. We describe 2 patients with this rare and unique arteriovenous network and discuss the issue of diagnosis and treatment with a review of the literature.

Superior vena cava syndrome secondary to recurrent coronary artery fistula: A case report and literature review

RATIONALE

Coronary artery fistula (CAF) is characterized by an abnormal communication of a coronary artery with a cardiac chamber or a great vessel bypassing the capillary bed. Surgical closure of large or symptomatic CAF is the gold standard treatment. However the previously closed CAF still has the possibility to reopen. Superior vena cava syndrome (SVCS) is defined as a condition that occurs when the obstruction of the superior vena cava interrupts blood flow from the head, upper extremities, and thorax to the right atrium and can present a life-threatening situation. In this report, we described a case of SVCS, which was secondary to the compression by a huge aneurysm formed in a recurrent CAF, as a long-term complication associated with surgical treatment of CAF.

PATIENT CONCERNS

A 47-year-old woman presented with chief complaint of progressive exertional dyspnea for one month.

DIAGNOSES

Superior vena cava syndrome and recurrent coronary artery fistula.

INTERVENTIONS

Reoperation for ligation of the fistulous and excision of the aneurysm were performed.

OUTCOMES

The patient made an uneventful recovery and her postoperative course through 1-year follow-up was uneventful.

LESSONS

First, SVCS is a rare but clinically important postoperative complication of surgical ligation of CAF. Second, surgical ligation of the fistula alone is unlikely to prevent the ectatic course. Therefore, long-term follow-up is mandatory for patients with CAF undergoing surgical closure.

Myocardial ischemia induced by major aortopulmonary collateral arteries treated with transcatheter coil embolization

Major aortopulmonary collateral arteries branching from coronary arteries may cause coronary steal. The careful follow‐up is needed irrespective of symptoms because increasing physical activities and oxygen demand along with the age may induce myocardial ischemia. Transcatheter intervention by well‐trained physician would be a treatment option in patients with myocardial ischemia.

Coronary Arteriovenous Fistulas in Adult Patients: Surgical Management and Outcomes

Objective

The aim of this study was to describe the demographic, clinical and anatomic characteristics of coronary arteriovenous fistulas in adult patients who underwent open cardiac surgery and to review surgical management and outcomes.

Methods

Twenty-one adult patients (12 female, 9 male; mean age: 56.1±7.9 years) who underwent surgical treatment for coronary arteriovenous fistulas were retrospectively included in this study. Coronary angiography, chest X-ray, electrocardiography and transthoracic echocardiography were preoperatively performed in all patients. Demographic and clinical data were also collected. Postoperative courses of all patients were monitored and postoperative complications were noted.

Results

A total of 25 coronary arteriovenous fistulas were detected in 21 patients; the fistulas originated mainly from left anterior descending artery (n=9, 42.8%). Four (19.4%) patients had bilateral fistulas originating from both left anterior descending and right coronary artery. The main drainage site of coronary arteriovenous fistulas was the pulmonary artery (n=18, 85.7%). Twelve (57.1%) patients had isolated coronary arteriovenous fistulas and 4 (19.4%), concomitant coronary artery disease. Twenty (95.3%) of all patients were symptomatic. Seventeen patients were operated on with and 4 without cardiopulmonary bypass. There was no mortality. Three patients had postoperative atrial fibrillation. One patient had pericardial effusion causing cardiac tamponade who underwent reoperation.

Conclusion

The decision of surgical management should be made on the size and the anatomical location of coronary arteriovenous fistulas and concomitant cardiac comorbidities. Surgical closure with ligation of coronary arteriovenous fistulas can be performed easily with on-pump or off-pump coronary artery bypass grafting, even in asymptomatic patients to prevent fistula related complications with very low risk of mortality and morbidity.

Anomalous Coronary Arteries That Need Intervention: Review of Pre- and Postoperative Imaging Appearances

Coronary artery anomalies constitute a diverse group of abnormalities, ranging from anatomic variants to those having hemodynamic consequences. This review focuses on major anomalies that have clinical implications requiring treatment, including anomalous origin of the coronary artery from the opposite sinus with interarterial course specifically with an intramural course, coronary artery origin from the pulmonary artery, and coronary artery fistula. Comprehensive imaging evaluation is necessary to precisely delineate the anatomy as well as pathophysiologic aspects of the anomaly before determining treatment options for a specific patient. Coronary computed tomographic angiography provides elegant depiction of coronary arterial anatomy and the relationship of the vessel to the adjacent structures, with the ability to perform three-dimensional reconstructions. Magnetic resonance (MR) imaging is emerging as an alternative noninvasive imaging strategy, particularly in young individuals, due to the lack of ionizing radiation and avoidance of iodinated contrast agents. This review describes the roles and recent technical advancements in computed tomography and MR imaging pertinent to coronary artery imaging. Additionally, this article will familiarize readers with the cross-sectional imaging appearance of clinically relevant coronary anomalies, hemodynamic considerations, and complex decision making. The different management strategies used for these anomalies, such as coronary unroofing, reimplantation, bypass grafting, Takeuchi repair, and surgical and interventional closure of fistulas, as well as specific posttreatment complications, are also discussed. ^©RSNA, 2017.

Minimally invasive approach for coronary artery fistula correction

Objectives

Minimally invasive cardiac surgery has recently become widespread. The aim of this study is to analyse the feasibility of a minimally invasive approach for coronary artery fistula (CAF) correction.

Methods

From February 2001 to June 2014, 49 patients in our centre underwent minimally invasive CAF correction without cardiopulmonary bypass (CPB). The mean age was 21.18 ± 11.24 years (range, 5 months to 64 years). Patients with cardiac anomalies who underwent CAF correction and those who underwent CAF via the minimally invasive approach with CPB were excluded.

Results

There were no in-hospital mortalities or conversions to median sternotomy. Subxiphoid incisions (22 cases) and parasternal incisions (20 cases) were the most commonly used approaches for the procedure. The operative time was 67.45 ± 22.69 min (30-125 min). The intubation time was 3.72 ± 1.82 h (2-12 h), and the ICU stay was 9.67 ± 5.43 h (4-24 h). A trivial residual shunt was identified in only 1 patient during the procedure; however, this shunt had disappeared by discharge.

Conclusions

The minimally invasive approach can provide excellent surgical exposure for CAF ligation in select patients. This approach is a safe and cosmetic alternative to conventional treatment and may minimize the length of stay.

Congenital coronary artery fistulas complicated with pulmonary hypertension: Analysis of 211 cases

AIM

To compare the behavior of pulmonary hypertension (PHT) associated with coronary artery fistulas (CAFs) between the Asian and Caucasian subjects.

METHODS

CAFs may be complicated with PHT secondary to left-to-right shunt. Literature review limited to the English language. A total of 211 reviewed patients were collected. Of those, 111 were of Asian and 100 were of Caucasian ethnic origin. The mean age of the Asian and the Caucasian groups of patients were 48.9 (range 19-83) and 49.9 years (range 16-85), respectively. In both groups, right heart catheterization was the most commonly (95%) used method for determining pulmonary artery pressure.

RESULTS

From all of the reviewed subjects, PHT was found in 49 patients (23%), of which 15 were Asian and 34 were Caucasian. In 75% of PHT subjects, mild to moderate PHT was reported and 76% of the fistulas had a vascular mode of termination. Treatment was surgical in 61%, followed by percutaneous therapeutic embolization (27%) and finally conservative medical management in 12% of PHT subjects. PHT was associated with a slight female gender predominance. The majority demonstrated mild to moderate PHT. PHT was reported more frequent in the Caucasian compared with the Asian ethnicity group. The majority of fistulas in patients with PHT had a vascular mode of termination. The results of this review are intended to be indicative and require cautious interpretation.

CONCLUSION

The likelihood for a CAF patient to develop PHT is presented when possessing the following features, with a Caucasian female having a fistula with a vascular mode of termination.

Pediatric coronary artery fistula: echocardiographic case reports and literature review of treatment strategy

Background

Coronary artery fistula (CAF) is a rare cardiac anomaly. Application of transthoracic echocardiography (TTE) is not fully illustrated in pediatric period. Meanwhile, the treatment strategy of CAF is still a controversial issue.

Case presentation

Five cases of CAF with different types were presented. We also retrospectively reviewed 32 records of CAF in our institution from May 2001 to January 2015, including cardiac murmurs, symptoms, TTE diagnoses, complications, other anomalies, treatment and outcome. We summarized the most acceptable treatment strategy for pediatric patients. 71.9 % of all (23/32) had murmurs, 15.6 % of all (5/32) had symptoms. 24 patients received surgery or other imaging examination after TTE. 87.5 % of all (21/24) were correctly and accurately diagnosed by echocardiography, including pointing out the origin and outlet of CAF and complication. During the followup of all 32 patients, there was no spontaneous closure, heart failure, infective endocarditis or death case.

Conclusions

TTE is a useful method that should be considered in the investigation and follow up of pediatric coronary artery fistula. The treatment strategy for pediatric patients should be individuation.