Persistent thebesian veins presenting with myocardial ischemia

Congenital Anomaly Diagnosis of Typical Cardiac Chest Pain Due to Thebesian Veins Draining Into the Left Ventricular Chamber: A Case Report and Review of Literature

Thebesian veins are microfistulae that drain the coronary arteries directly into one or more chambers of the heart. Persistence of these anomalous connections into adulthood can lead to shunting of blood away from the myocardium causing typical chest pain symptoms with electrocardiogram changes consistent with ischemia. We describe a case of a 77-year-old female who underwent ischemic evaluation for her symptoms found to have significant Thebesian veins. We also engage in a comprehensive review of the literature finding consistencies in the way these cases are presented in the literature.

Angiographically detectable Thebesian veins are a dynamic and reversible finding in the setting of congenital heart disease

OBJECTIVE

Angiographically detectable Thebesian veins (ThVs) are a rare finding sometimes associated with coronary steal and myocardial ischemia in adults, but there are limited data regarding prominent ThVs in the setting of complex congenital heart disease (CHD). This study represents the largest series to date describing the presence and temporal changes of angiographically detectable ThVs in children with CHD.

METHODS

This is a single center case series describing the clinical characteristics and coronary anatomy in children with CHD and angiographicall detectable ThVs. After identification of the index case, additional patients were identified in a prospective manner during the course of routine clinical care. We developed a qualitative scale to grade ThV burden, with changes tracked over time in the subset of patients who underwent serial cardiac catheterizations.

RESULTS

A total of 10 patients are included in this report. There was a predominance of female gender (8 of 10 patients), right-dominant single ventricle physiology (7 of 10 patients), and heterotaxy syndrome (6 of 10 patients). The degree and location of epicardial coronary artery tortuosity was qualitatively related to ThV burden. The subset of patients who underwent serial cardiac catheterizations demonstrate that ThV dilation can progress or regress over time.

CONCLUSIONS

Angiographically detectable Thebesian veins are a rare finding in patients with congenital heart disease and may represent global changes in the coronary circulation. This is the first report, adult or pediatric, to demonstrate that ThV dilation is a dynamic process capable of both progression and regression. The physiologic impact of these findings remains to be elucidated.

Cardiac Structural Changes and Long-Term Survival in Patients With Prominent Thebesian Veins

Although rare, numerous case reports suggest that Thebesian veins confer increased morbidity and mortality. No study has evaluated their effects on cardiac structure or long-term patient outcomes. Patients undergoing coronary angiogram at the study institution from October 2002 and January 2015 were assessed for a diagnosis of prominent Thebesian veins. A matched control group was created and comparisons between clinical, echocardiographic, and survival measures were made. Of 50,116 total patients, 31 (0.06%) were found to have prominent Thebesian veins on angiography and were compared with a matched control group of 596 patients. Patients were matched for age, gender, angiogram date, location and extent of coronary disease, and dominance. Demographic and clinical data were similar between cohorts, with a median follow-up period of 26 months. Patients with Thebesian veins had lower Doppler E wave (0.7 vs 0.8; p = 0.007) and A wave (0.6 vs 0.8; p = 0.001) mitral inflow velocities suggesting some decrease in normal mitral inflow, potentially due to direct shunting into the ventricle from the Thebesian vein network. However, there was no observed difference in left ventricular size or ejection fraction between groups. There was also no significantly increased mortality associated with the presence of Thebesian veins (hazard ratio 1.11, 95% CI 0.58 to 2.13). In conclusion, although previous reports have suggested adverse outcomes from Thebesian veins, our case-control study demonstrated no significant associated adverse cardiac structural changes or increase in mortality, although patients with Thebesian veins were noted to have a decrease in mitral inflow velocities.

Severe form of persistent thebesian veins presenting as ischemic heart disease

Coronary artery fistula is a rare congenital anomaly. Most patients with this anomaly are asymptomatic, but some may develop heart failure, myocardial ischemia or arrhythmias. We report a case of a patient who presented with myocardial ischemia secondary to persistent Thebesian veins. Coronary angiography demonstrated a marked capillary blush draining into the left ventricular cavity through multiple microfistulae from the left anterior descending artery, left circumflex artery and right coronary artery. The patient was discharged without chest pain and was medically maintained with a beta-blocker and angiotensin converting enzyme inhibitor.

Aortic regurgitation and coronary microfistulae: double jeopardy causing myonecrosis

We describe a 3-case series of patients with a rare combination of mild-to-moderate aortic regurgitation and coronary microfistulae but nonobstructed epicardial coronary arteries who presented with symptoms of unstable angina and had confirmed myonecrosis. A plausible pathophysiological mechanism for this phenomenon and its clinical implication are discussed.