Surgical experience of coronary artery-right ventricular fistula in a heart transplant patient

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.

Percutaneous iatrogenic coronary fistula closure in heart transplant recipient

A 61-year-old man with ischemic cardiomyopathy underwent orthotopic heart transplantation. On routine coronary angiography 1 year later, a huge fistula was seen between the left anterior descending coronary artery and the right ventricle. When the patient developed symptoms of ischemia 8 years later, the fistula was successfully closed percutaneously, using a covered stent.

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.

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.

Transcatheter embolisation of an enlarging acquired coronary arteriovenous fistula in a heart transplant recipient

A 50 year old, recent cardiac transplant recipient developed systolic and diastolic murmurs but remained asymptomatic. The cause of the murmurs was not evident at transthoracic echocardiography. During routine left heart catheterisation a left anterior descending artery to right ventricular fistula was evident arising from the distal vessel and presumably acquired during routine endomyocardial biopsy. One year later, the patient remained asymptomatic but the calibre of the left anterior descending artery had increased and there appeared to be poor flow in to the proximal branches. The fistula was successfully treated by percutaneous deployment of two detachable embolisation coils in to the distal left anterior descending artery.