Congenital coronary arteriovenous fistula. Report of 13 patients, review of the literature and delineation of management

Mitral valve infective endocarditis with spread of infection to the pulmonary valve via coronary artery pulmonary artery fistula: a case report

BACKGROUND

In cases of left-sided infective endocarditis (IE) complicated by one or more lung abscesses, close examination should be performed with the additional presence of right-sided IE in mind. Pulmonary valve IE may occur via a coronary artery pulmonary artery fistula (CAPAF) even in the absence of vegetation at the tricuspid valve.

CASE PRESENTATION

A 76-year-old male was admitted to his local hospital with back pain and weight loss that had started 4 months previously. He was diagnosed with vertebral osteomyelitis, and antibiotic therapy was started. Subsequently, echocardiography revealed mobile vegetation at the mitral valve, and computed tomography (CT) showed multiple lung abscesses. The patient was then transferred to our hospital for urgent surgical intervention. Additional echocardiography revealed no visible vegetation at the tricuspid valve but did show thickening and moderate regurgitation of the pulmonary valve. These results indicated the presence of pulmonary valve IE. In addition, coronary CT angiography revealed CAPAF and intraoperative findings showed vegetation on the pulmonary valve. Therefore, mitral valve replacement (MVR), pulmonary valve replacement (RVR), and CAPAF closure were performed.

CONCLUSIONS

The present report is thought-provoking to describe the diagnosis of and surgical planning for IE. Firstly, when left-sided IE is complicated by lung abscess, a detailed evaluation of the right heart system and the potential for a left-to-right shunt should be performed, keeping in mind the possible presence of right-sided IE. Secondly, even if there is no vegetation at the tricuspid valve, there may be vegetation at the pulmonary valve, in which case an extracardiac left-to-right shunt that does not pass through the tricuspid valve may be present. CAPAF is a rare anomaly, but it causes pulmonary valve IE, which requires PVR.

A Rare Cause of a Continuous Murmur in a Newborn

We describe what we believe to be the first reported case of a neonate with right coronary ostial atresia with the right coronary artery originating from the left circumflex coronary artery, in conjunction with a right coronary artery to right ventricle fistula in a patient with otherwise normal cardiac anatomy. This was found following an evaluation for a continuous murmur at 2 weeks of life with elevated troponin and abnormal electrocardiogram. Thus far the child has required no intervention and is asymptomatic at 17 months of age, but he will require long-term follow-up to monitor the size of the fistula and potential for myocardial insufficiency.

Percutaneous Coil Closure of a Large Left Coronary Artery Fistula in an Asymptomatic Child

Coronary artery fistulas (CAFs) are rare cardiac anomalies characterized by an abnormal connection between the coronary arteries and either a cardiac chamber or a large thoracic vessel. While the majority of CAF cases are asymptomatic, serious cardiac complications can occur, especially with moderate to large fistulas. We describe a case of a large-sized left coronary artery (LCA) fistula in an asymptomatic 11-year-old who was referred for cardiac evaluation due to a systolic murmur. An echocardiogram revealed a hemodynamically significant fistula arising from the LCA draining into the right ventricle. Diagnostic catheterization confirmed the origin and draining site of the fistula, along with aneurysmal dilation at the end of the fistula. The fistula was successfully closed percutaneously using a two-coil occlusive device, with no complication observed.

Surgical Management of Coronary Artery Fistulas in Children

Background

This study investigated the surgical outcomes associated with coronary artery fistulas (CAFs) in children.

Methods

We retrospectively reviewed the medical records of 23 pediatric patients who underwent surgical closure of CAFs between 1995 and 2021. At presentation, 7 patients (30.4%) exhibited symptoms. Associated cardiac anomalies were present in 8 patients. Fourteen fistulas originated from the right coronary artery and 9 from the left. The most common drainage site was the right ventricle, followed by the right atrium and the left ventricle. The median follow-up duration was 9.3 years (range, 0.1-25.6 years).

Results

The median age and body weight at repair were 3.1 years (range, 0-13.4 years) and 14.4 kg (range, 3.1-42.2 kg), respectively. Cardiopulmonary bypass was used in 17 cases (73.9%), while cardioplegic arrest was employed in 14 (60.9%). Epicardial CAF ligation was utilized in 10 patients (43.5%), the transcoronary approach in 9 (39.1%), the endocardial approach in 2 (8.7%), and other methods in 2 patients (8.7%). The application of cardioplegic arrest during repair did not significantly impact the duration of postoperative intensive care unit stay or overall hospital stay. One in-hospital death and 1 late death were recorded. The overall survival rate was 95.7% at 10 years and 83.7% at 15 years. A residual fistula was detected in 1 patient. During the follow-up period, no surviving patient experienced cardiovascular symptoms or coronary events.

Conclusion

Surgical repair of CAF can be performed safely with or without cardioplegic arrest, and it is associated with a favorable prognosis in children.

An unusual cause of acute coronary syndrome: thrombosis of right coronary artery to right atrium fistula

Coronary arterial fistulae are rare, but it is one of the most common coronary artery anomalies. Most of the cases are asymptomatic in younger patients unless it is large and of haemodynamic significance. The incidence of thromboembolic complications usually increases with age. We report a case of a young male in his early 20s presenting with central chest pain. Coronary computed tomographic angiography revealed acute coronary syndrome due to a fistula between right coronary artery and right atrium occluded by thrombus. After discussion with coronary and congenital heart multidisciplinary team, a consensus was agreed that we should manage him conservatively with anticoagulant and antiplatelet therapy and a 3-month follow-up strategy that included repeating cardiac imaging. After a year, his anticoagulation and antiplatelet medication was discontinued.

Diagnosis and Management of Congenital Coronary Artery Fistulas in Infants and Children

PURPOSE OF REVIEW

Coronary artery fistulas (CAFs) are rare coronary anomalies that most often occur as congenital malformations in children. Although most children with CAFs are asymptomatic at the time of diagnosis, some present with symptoms of congestive heart failure in the setting of large left-to-right shunts. Others may develop additional complications including coronary artery ectasia and coronary thrombosis. Surgical and transcatheter closure techniques have been previously described. This review presents the classifications of CAFs in children and the short and long-term outcomes of CAF closure in children in the reported literature. We also summarize previously-reported angiographic findings and post-treatment remodeling characteristics in pediatric patients.

RECENT FINDINGS

With advancements in cross-sectional imaging technologies, anatomic delineation of CAFs via these modalities has become crucial in procedural planning. Recent reports of surgical and transcatheter closure of CAFs in children have reported good procedural success and low rates of short-term morbidity and mortality. Distal-type CAFs have elevated risk for long-term sequelae post-closure compared to proximal-type CAFs. A recent report of a multi-institutional cohort also describes post-closure remodeling classifications which may predict long-term outcomes in these patients as well as guide individualized anticoagulation management. Invasive closure of significant CAFs via surgical or transcatheter techniques is feasible and safe in most children with good short and intermediate-term outcomes. However, close clinical and imaging follow-up is required to monitor for late complications even after successful closure. Antiplatelet and anticoagulation regimens remain important aspects of post-closure management, but the necessary intensity and duration of such therapy remains unknown.

Interventricular septal dissecting aneurysm resulting from congenital coronary fistula: A case report

Dissected interventricular septal aneurysm is a rare complication that occurs in conditions such as acute myocardial infarction, sinus valsalva aneurysm, infective endocarditis, thoracic trauma, pericardiocentesis and balloon angioplasty. Only two cases of dissected interventricular septal aneurysm secondary to coronary fistula have been described in the literature. Here, we present a case of dissected interventricular septal aneurysm secondary to congenital coronary fistula.

An unusual case of coronary artery fistula successfully treated by transcatheter approach

Coronary artery fistulas are rare, but one of the most common forms of congenital coronary abnormalities. These patients are often diagnosed incidentally undergoing coronary angiography, but with the advent of novel cardiac imaging tools, there is an increasing rate of detection as well as transcatheter management of these fistulas. Our case is unusual in a way that it involved a combination of two separate coronary artery fistulas arising from both the coronary systems draining into the same site.

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.

Left main coronary artery to pulmonary artery fistula presenting as angina and ventricular tachycardia - A case report and literature review

Coronary artery fistulae are an uncommon abnormality of the coronary arteries, but when hemodynamically significant can present as angina, dyspnea, and arrhythmia as a rare cause of functional myocardial ischemia via 'coronary steal phenomenon'.

Surgery of a Giant Coronary Sinus Aneurysm Resulting from a Coronary Artery Fistula

Coronary artery fistula (CAF), complicated by the aneurysmal formation of the coronary sinus (CS), is a very rare form of CAF. Here we report a case of a 60- year-old woman with a giant aneurysm of the CS resulting from the right coronary artery (RCA) fistula. The patient was highly symptomatic with dyspnea due to compression of cardiac chambers. CS reconstruction was performed using a pericardial patch after directly closing the fistula from the RCA to the CS.

A Phenotype and Genotype Case Report of a Neonate With Congenital Bilateral Coronary Artery Fistulas and Multiple Collateral Arteries

We report a unique case of an 18-day-old girl with three coronary artery fistulas to the right atrium and right ventricle, respectively: three collateral arteries arising from the descending aorta and one from the right subclavian artery draining through a sac to the top of the right atrium, patent ductus arteriosus, and atrial septal defect. She presented symptoms of acute congestive heart failure. Cardiac catheterization and surgical interventions were performed to repair the defects. The patient recovered uneventfully and grew up well at 3 years of follow-up. Whole-genome sequencing (WES) in the patient, compared to her parents, showed 17 variants within 11 genes. Among these, only compound heterozygous mutation, c.T470G (p.L157R) and c.A1622G (p.D541G), in the DRC1 gene have been reportedly related to congenital heart disease and are the most likely causative in our patient.

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.

Penetrating chest injury afflicting coronary artery fistula-A delayed and asymptomatic occurrence

We present here a case of a symptomatic chest injury with a nail gun causing a delayed occurrence of coronary artery fistula to the left pulmonary artery presenting with unstable angina 4 years after the initial injury, three of which were symptom-free. The patient underwent successful surgical closure of the fistula and removal of the foreign body.

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.

Innovative method to diagnose coronary Cameral fistula by contrast echocardiography

INTRODUCTION

Coronary artery fistula (CAF) is a rare cardiac anomaly that typically presents as a continuous murmur in an otherwise asymptomatic patient. Occasionally, it can result in congestive heart failure or bacterial endocarditis.

OBJECTIVE

To better delineate the course of coronary artery fistula using an intracoronary injection of SonoVue contrast agent, while performing transthoracic echocardiography.

METHOD AND RESULTS

A referred 46-year-old man, with a history of exertional dyspnea for almost 3 months, was admitted to the hospital with progressive dyspnea and assessed under suspicion of CAF. CAF was seen with a coronary angiogram, but the exact entry point in the left ventricle or left atrial wall could not be determined. CT angiography also failed to establish the drainage site, so CAG (coronary angiography) was repeated with the SonoVue contrast agent injected into LM (Left main) while using a Siemens echocardiography machine. Multiple views were obtained during the injection and revealed unusual flow in the left ventricle just below the PML (posterior mitral leaflet) and passing through the fistula to LV.

CONCLUSION

Contrast-enhanced echocardiography by direct intracoronary injection of SonoVue contrast agent is safe and can aid in the delineation of fistula drainage.

An Incidental Finding of Coronary-cameral Fistulas in a Critically Ill Patient with a Metastatic Cardiac Tumor

It is extremely rare for a cardiac tumor to present with coronary-cameral fistulas. A 66-year-old Caucasian male presented with worsening dyspnea and subsequently had a cardiac catheterization for an ST-elevation myocardial infarction, revealing no evidence of coronary artery disease but multiple coronary-cameral fistulas. Venoarterial (VA) extracorporeal membrane oxygenation was initiated for a severe cardiogenic shock. Workups including a transesophageal echocardiography and a right heart catheterization led to a diagnosis of metastatic melanoma involving both ventricles of his heart. Angiogenesis is well described in melanomas and our novel case reports the extremely rare association of coronary-cameral fistulas with a metastatic cardiac melanoma. How to cite this article: Thyagarajan B, Bryant C, Khanna AK. An Incidental Finding of Coronary-cameral Fistulas in a Critically Ill Patient with a Metastatic Cardiac Tumor. Indian J Crit Care Med 2021;25(3):340-342.

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.

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.

Coronary Artery Fistula

Coronary artery fistula (CAF) is an abnormal connection between a coronary artery and a heart chamber resulting in left-to-right shunt. A large CAF was an unexpected cause of heart failure in a 58-year-old woman who underwent transcatheter closure of the CAF with improvement in symptoms but complicated by myocardial infarction. (Level of Difficulty: Beginner.)

Electrocardiographic findings of Wellens syndrome due to coronary artery-pulmonary artery fistula

A coronary artery fistula (CAF) is an abnormal connection between a coronary artery and any of the four cardiac chambers, the large vessels, or other vascular structures. Wellens syndrome is an ST-segment elevation myocardial infarction equivalent. Although both Wellens syndrome and CAFs have been reported in the literature, they have rarely been reported in the same patient. We herein report a case clinically diagnosed as Wellens syndrome by electrocardiography (ECG) findings; coronary angiography subsequently showed a fistula originating from the left anterior descending artery and draining into the pulmonary artery. The ECG findings then returned to normal after the fistula had been closed by controlled-release coils. These events confirmed that the abnormal ECG findings of Wellens syndrome were due to the CAF.

A Large Isolated Congenital Left Circumflex Artery-to-Right Atrial Fistula in a 9-Year-Old Child

Isolated congenital coronary artery fistula (ICCAF) is an exceedingly rare anomaly in which there is a direct abnormal connection between a coronary artery and other cardiac chambers or any of great vessels. The left circumflex artery (LCX) is the least common source of ICCAF. Here we reported a rare case of large ICCAF originated from the LCX in a 9-year-old boy. He presented fatigability, murmurs and NYHA class II. Echocardiography and cardiac CT revealed that an aneurysmal dilatation of the LCX along with the dilated coronary sinus entered into the right atrium (RA) through the great cardiac vein. However, it showed that the dilated LCX directly drained into the RA by coronary angiography, which was confirmed by the surgery. During the surgical procedure, the LCX fistula was identified in a 3^*3 cm bulbous structure, the aneurysmal dilation of RA tissue. The end of fistula was located in the lower-middle interatrial septum, which was near the coronary sinus and above the opening of inferior vena cava (IVC). Transcardiac chamber closure with cardiopulmonary bypass (CPB) was successfully performed for the correction of the fistula. It indicated that preoperative angiography is essential to define the details of large ICCAF with aneurysmal dilation. Moreover, transcardiac chamber closure with CPB is the optimal procedure for the treatment of large ICCAF, while interventional catheterization is not feasible due to the presence of aneurysmal dilation of the LCX. The description of this rare case might have great value for the diagnosis and treatment of large ICCAF originated from the LCX.

Early and late presentation of coronary artery fistula: a possible natural progression?

We present two patients, one 10 years old and another 43 years old, who both had successful transcatheter closure of left main coronary artery to right atrium fistulas. The older patient had a larger fistula as well as more symptoms and a complicated post-procedure course. Closure of medium or large coronary artery fistulas should be considered at younger ages to minimise future complications.

Congenital coronary artery fistula: Presentation in the neonatal period and transcatheter closure

BACKGROUND

Congenital coronary artery fistula is a rare coronary anomaly. Most commonly, such fistulae drain into the right side of the heart or the pulmonary artery. Children with coronary artery fistulae are generally asymptomatic, although they may have left ventricular enlargement in the setting of a moderate sized left to right shunt. Symptoms of congestive heart failure or ischemia are very rare in neonatal period, and suggest the presence of a very large shunt and/or coronary steal.

METHODS

Single center retrospective review of transcatheter intervention on coronary artery fistulae presenting with symptoms in the neonatal period from January 2000 to March 2018. Patients with associated congenital heart diseases (except atrial septal defect) were excluded. Patient records, catheterization data, angiograms and noninvasive imaging were reviewed.

RESULTS

Two patients underwent transcatheter intervention for symptomatic coronary artery fistula in the first few weeks of life. The first patient had multiple right and left coronary artery to right ventricle fistulae and presented with severe biventricular systolic dysfunction. Transcatheter closure of the fistulae was performed using multiple Gianturco coils. The second patient had a large left main coronary artery to left ventricle fistula (with left anterior descending and circumflex coronary artery atresia) presenting with symptoms of ischemia. This large fistula was closed using one Amplatzer Vascular Plug type-II and two Micro-Vascular Plugs. Both patients had improvement in symptoms post intervention and are doing well at the last follow up at 12 years and 7 months respectively.

CONCLUSIONS

We hereby describe the rare presentation of symptomatic coronary artery fistulae in the neonatal period and their successful transcatheter management. This is also the first description of left anterior descending and circumflex coronary artery atresia in the setting of a large left main coronary artery to left ventricle fistula.

Coronary cameral fistula: case report

Introducción. Una fístula coronaria se define como la comunicación entre una arteria coronaria y una cámara cardiaca o cualquier segmento de la circulación sistémica o pulmonar. Su incidencia en series angiográficas y población general es muy baja y, en general, cursan de modo asintomático, aunque en raras ocasiones presentan significancia hemodinámica. Su localización en cavidades izquierdas es menos frecuente. Presentación del caso. Paciente masculino de 52 años quien presenta angina de esfuerzo, por lo que fue estratificado de modo invasivo encontrándose una fístula coronaria de la arteria descendente anterior al ventrículo izquierdo. Ante dichos hallazgos, le fue solicitada resonancia magnética nuclear cardiaca como estudio complementario para determinar conducta terapéutica a futuro; sin embargo, el paciente no asistió a controles, ni se le realizó dicho examen. Discusión. Las fístulas coronarias que causan enfermedad arterial coronaria son raras y el drenaje de una fístula coronaria a ventrículo izquierdo es aún más infrecuente. La importancia fisiopatológica de una fístula coronaria está relacionada con el volumen de sangre que fluye y el gradiente de presión a través de la comunicación. La mayoría de fístulas coronarias son diagnosticadas incidentalmente en un cateterismo cardíaco; sin embargo, algunas de estas presentan significancia clínica, siendo sintomáticas y causando complicaciones, por lo que requieren tratamiento a corto plazo. Conclusiones. En algunos casos, las pruebas complementarias iniciales en pacientes con clínica de isquemia miocárdica, realizadas de modo no invasivo, permiten sospechar la presencia de fístulas coronarias. La angiografía coronaria continúa siendo la prueba de mayor precisión diagnostica. Además, se deben tener en cuenta las características anatómicas y fisiológicas para definir si requieren manejo y si este se hará por vía percutánea o quirúrgica.

Is Fractional Flow Reserve Useful in Assessing Coronary Artery Fistula: A Case-Based Discussion and Review

We present two cases where fractional flow reserve (FFR) was utilised to guide management of coronary artery fistula (CAF), an approach advocated in recent case studies. CAF is a coronary anomaly that may present with a variety of syndromes though is frequently asymptomatic. When to exclude the fistula (surgically or percutaneously) is not always clear. A way to quantify if the fistula is physiologically meaningful would be advantageous. Our findings suggest FFR may only be assessing the concomitant epicardial coronary artery disease (CAD) rather than the degree of coronary steal and its routine use in this setting is not supported.

Coronary Artery Fistulae: Anatomy, Diagnosis and Management Strategies

Coronary artery fistula (CAF) is a relatively rare anatomic abnormality of the coronary arteries that afflicts 0.002% of the general population and represents 14% of all the anomalies of coronary arteries. Its clinical relevance focusses mainly on the mechanism of "coronary steal phenomenon", causing myocardial functional ischaemia even in the absence of stenosis, hence common symptoms are angina or effort dyspnoea. The suggested diagnostic approach is guided by the patient's symptoms and consists of a number of instrumental examinations like ECG, treadmill test, echocardiography, computed tomography scan, cardiac magnetic resonance and coronary angiography. If it is not an incidental finding, coronary angiography is required in view of the optimal therapeutic planning. Small-sized fistulae are usually asymptomatic and have an excellent prognosis if managed medically with clinical follow-up with echocardiography every 2 to 5 years. In the case of symptomatic, large-sized or giant fistulae an invasive treatment, by transcatheter approach or surgical ligation, is usually a reasonable choice, and both strategies show equivalent results at long-term follow-up. Antibiotic prophylaxis for the prevention of bacterial endocarditis is recommended in all patients with coronary artery fistulae who undergo dental, gastrointestinal or urological procedures. A life-long follow-up is always essential to ensure that the patient is not undergoing progression of disease or further cardiac complications.

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.

Cardiac Computed Tomography as an Imaging Modality in Coronary Anomalies

Coronary artery fistulae and coronary aneurysms are rare anomalies. When they become symptomatic, they require precise anatomic information to allow for planning of the therapeutic procedure. We report a case in which both fistulae and aneurysm were present. The required information could only be obtained by electrocardiogram-gated computed tomography with reformation. This imaging modality should be considered in every case of fistula or coronary aneurysm.

Surgical Treatment of Coronary to Pulmonary Artery Fistulas in Adults

Coronary to pulmonary artery fistulas (CPAFs) are abnormal communications between the coronary and pulmonary arteries. They are an uncommon congenital heart disease and usually remain asymptomatic until later in life. However, there is no consensus on their management. We present four adult patients who required surgery for coronary to pulmonary artery fistulas to illuminate this issue. The clinical presentations were variable depending on the anatomical features of coronary to pulmonary artery fistulas and the presence or absence of other cardiac diseases. We successfully performed surgical closure of the coronary to pulmonary artery fistulas in each of the cases. In this report, we describe our experience with these cases and outline the available therapeutic strategies and treatment options for coronary to pulmonary artery fistulas.