Coronary Artery Fistula-Associated Endocarditis: Report of Two Cases and a Review of the Literature

Infective Endocarditis of a Coronary Artery Fistula With Aortic Valve Involvement

•CAF is a rare congenital coronary artery anomaly. •IE is a rare complication of CAF. •Both TEE and CT angiography can identify CAF and its origin and drainage site. •TEE has higher sensitivity than CCT in diagnosing vegetations. •Antibiotic prophylaxis is recommended for all patients with congenital CAFs.

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.

Case report: Surgical repair for left main coronary artery to right atrium fistula with endocarditis

Coronary artery fistula (CAF) is a rare coronary anomaly defined as a communication between coronary artery and other heart chambers or vascular structures. In this case report, a 32-year-old woman with a giant left main coronary artery to the right atrium fistula with endocarditis was presented. CAF was diagnosed by transthoracic echocardiography and subsequently confirmed by cardiac computerized tomographic and coronary angiography. The patient received antibiotic treatment for infective endocarditis for 6 weeks preoperatively. The fistula was successfully treated with surgical repair. The patient is well now after 18 months of follow-up.

Long-Term Follow-Up of Pediatric Patients After Congenital Coronary Artery Fistula Closure

The surgical closure of congenital coronary artery fistulas (CAF) is associated with excellent immediate outcomes. Few studies have investigated the long-term prognosis in patients who have undergone surgery for the closure of CAF or differentiated among types of CAF or types of surgical procedures. In this study, we performed clinical examinations and computed tomography angiography (CTA) to characterize outcomes after CAF closure in pediatric patients. The medical records of 79 pediatric patients who underwent surgical closure of CAF were retrospectively reviewed. The median age of the patients included in the study at the time of surgery was 3.4 years (range 0.2 to 15.3 years). The patients had been followed up for 11 years (range 1 to 17 years) with electrocardiography, echocardiography, and coronary CTA. There were 67 medium-to-large CAF and 12 small CAF. Twenty-six (32.9%) CAF arose from the branch coronary artery (proximal type); the others arose from the parent coronary artery (distal type). The surgical procedure included endocardial closure in 16 cases, epicardial distal ligation in 51 cases, epicardial proximal and distal ligation in 12 cases. There was no instance of perioperative death among the cases included in the study. Twenty-eight patients were treated with antiplatelet medication postoperatively. No patient required re-operation during the follow-up period. Coronary thrombi were detected in 27 patients (34.2%). There was no instance of myocardial ischemia related to thrombosis. Among the patients with thrombosis, 26 had medium-to-large CAF (96.3%), and 23 had distal-type CAF (85.2%). Average age at surgery was higher among the patients with thrombosis than among the patients without thrombosis (7.4 years vs. 3.3 years, t = 5.509, P = 0.000). Among the patients with distal-type CAF, thrombosis was more common among the patients treated with ligation than treated with endocardial closure (41.5% vs. 16.7%, χ² = 3.742_, P = 0.043). There was no difference in risk for thrombosis between the patients who did vs. did not receive antiplatelet therapy (P = 0.436). The most common complication after CAF closure was thrombosis. Increased risk for thrombosis was associated with large fistulae, distal-type CAF, and older age at presentation. Antiplatelet treatment did not appear to decrease the risk of thrombosis. Among patients with distal-type CAF, risk for thrombosis was lower among patients treated with endocardial closure, compared with patients treated with epicardial ligation.