Tortuous right coronary artery to coronary sinus fistula

Transcoronary sinus repair of a severely dilated and tortuous right coronary artery fistulized to coronary sinus complicated with tricuspid valve insufficiency

BACKGROUND

Right coronary artery (RCA) fistulized to the coronary sinus is rare condition in adult cardiac anomalies, and the management and operative indication are controversial.

CASE PRESENTATION

We describe the case of a 45-year female patient who presented with exertional dyspnea, accompanied by intermitted lower limbs and facial edema. She was diagnosed with severe tricuspid regurgitation second to a severely dilated RCA fistulized to the coronary sinus. After multidisciplinary discussion, she underwent surgery through routine medium sternotomy, the right atrium was opened under cardiopulmonary bypass. The coronary arteriovenous fistula from the distal portion of RC to a severely enlarged coronary sinus was found. Trans-coronary sinus closure of the fistula was performed with continuous stitching and a tricuspid ring annuloplasty was done. The patient recovered uneventful post operation.

CONCLUSION

According to current literatures, surgical treatment was adopted for this case, instead of endovascular intervention. The optimal approach for these cases should consider the heart's anatomical characteristics. But we need to be aware of the occurrence of myocardial infarction and tricuspid regurgitation in the early and late stage after operation.

An unusual pair: coronary artery fistula and coronary sinus ostium stenosis as a cause of refractory angina

Background

Coronary fistula are rare and often present in early adulthood with symptoms of right heart overload from left to right shunting or ischaemia in the distal coronary bed due to coronary steal.

Case summary

A 73-year-old lady with prior history of supraventricular tachycardia, dyslipidemia and a right coronary artery (RCA) to coronary sinus (CS) fistula, presented with progressive angina. She did not have evidence of ischaemia in the RCA territory on nuclear imaging, and cardiac computed tomography (CT) did not show coronary artery disease but revealed a significantly dilated CS and coronary venous tree. She was found to have CS ostial stenosis and, under transesophageal echocardiographic guidance, underwent successful balloon angioplasty of the CS ostium, with decompression of the coronary venous circulation and resolution of her angina.

Discussion

Coronary fistula draining to the CS are rare, and association with CS ostial stenosis has been reported very infrequently. CS ostial stenosis can cause elevated coronary venous pressure, leading to decreased global coronary perfusion and symptoms of angina or heart failure. Previous case reports of coronary fistula and CS ostial stenosis were treated with either medical therapy or surgery, and our case is the first to our knowledge to report successful percutaneous treatment.

Case Report: Congenital Coronary Artery Ring With Single Left Coronary Ostium and Fistula: A Previously Unreported Anatomy

Background: Single coronary ostium concomitant with coronary artery fistula is a very rare congenital anomaly. Apart from that, the combination of a closed loop of the coronary artery has never been reported. Case presentation: Herein, we present a 7-year-old girl diagnosed as single left coronary ostium with a giant coronary trunk, coronary artery to right ventricle fistula, and coronary artery ring. The coronary fistula was surgically ligated with off-pump strategy and the patient discharged on postoperative day 5 and free of symptoms during the 3 years of follow-up. Conclusion: To our knowledge, the presented congenital coronary anomaly is the first to be reported in the literature with the name of congenital coronary artery ring with single left coronary ostium and fistula.

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.

Coronary artery fistula between single right coronary artery and right pulmonary artery: a case report and literature review

Background

Coronary artery fistula and single coronary artery are two different rare congenital anomalies. The cases with co-existed the two anomalies are more rare. To the best of our knowledge with literature review, the coronary artery fistula between single right coronary artery and right pulmonary artery has not been previously reported.

Case presentation

In the present article, we report a Chinese patient (a 8-month-old male) who presented cyanosis when cried and heart murmur. The cardiac angiography confirmed coronary artery fistula between single coronary artery arising from the right aortic sinus and right pulmonary artery. Furthermore, the right pulmonary artery was interrupted with main pulmonary artery and the pulmonary blood supplied by single right coronary artery. Following the surgical procedure, the anomalous fistula vessel was cut and sutured. The right pulmonary artery was reconstructed to connect with main pulmonary artery. The patient had an uneventful postoperative course and discharged. Then we reviewed the related literature with Medline and Pubmed databases for further details.

Conclusion

We believe our patient is the very particular case about coronary artery fistula combined with single coronary artery, and it is first reported with our literature review. As other coronary anomalies, coronary or aortic root angiography is the gold standard method for the diagnosis. Furthermore, early surgery is an optimal treatment in our case.

Electronic supplementary material

The online version of this article (doi:10.1186/s12872-015-0166-2) contains supplementary material, which is available to authorized users.

Computed tomography and magnetic resonance imaging of the coronary sinus: anatomic variants and congenital anomalies

The coronary sinus (CS) is an important vascular structure that allows for access into the coronary veins in multiple interventional cardiology procedures, including catheter ablation of arrhythmias, pacemaker implantation and retrograde cardioplegia. The success of these procedures is facilitated by the knowledge of the CS anatomy, in particular the recognition of its variants and anomalies. This pictorial essay reviews the spectrum of CS anomalies, with particular attention to the distinction between clinically benign variants and life-threatening defects. Emphasis will be placed on the important role of cardiac CT and cardiovascular magnetic resonance in providing detailed anatomic and functional information of the CS and its relationship to surrounding cardiac structures.

Teaching Points

• Cardiac CT and cardiovascular magnetic resonance offer 3D high-resolution mapping of the coronary sinus in pre-surgical planning.

• Congenital coronary sinus enlargement occurs in the presence or absence of a left-to-right shunt.

• Lack of recognition of coronary sinus anomalies can lead to adverse outcomes in cardiac procedures.

• In coronary sinus ostial atresia, coronary venous drainage to the atria occurs via Thebesian or septal veins.

• Coronary sinus diverticulum is a congenital outpouching of the coronary sinus and may predispose to cardiac arrhythmias.

A giant coronary artery aneurysm with coronary arteriovenous fistula in asymptomatic elderly patient

Coronary Arteriovenous Fistula (CAF) is a rare defect that occurs in 0.1-0.2% of patients undergoing coronary angiography; Coronary Artery Aneurism (CAA) also occurs in approximately 15-19% of patients with CAF. It is usually congenital, but in rare occasions it occurs after chest trauma, cardiac surgery, or coronary interventions. The case described is that of a 72-year-old woman, without previous history of cardiovascular disease, who presented a huge cardiac mass. A multimodal approach was necessary to diagnose a giant CAA with CAF responsible for compression and displacement of cardiac structures. Due to likely congenitally origin of the lesion and the absence of symptoms correlated to the CAA and to the CAF we decided to avoid invasive interventions and to treat the patient with medical therapy.

Congenital giant right coronary artery aneurysm with fistula to the coronary sinus and persistent left superior vena cava in an old woman

The combination of coronary arteriovenous fistula to the coronary sinus (CS), dilatation of the entire length of coronary artery, coronary aneurysm and persistent left superior vena cava (PLSVC) is very rare. We present the case of a 63-year-old female admitted for dyspnea on exertion, orthopnea, and facial edema. Echocardiography detected a giant coronary artery with shunt flow, dilated CS and PLSVC and a coronary angiography reaffirmed these findings. The calculated ratio of pulmonary blood flow to systemic blood flow by cardiac catheterization was 1.53. After multidisciplinary review considering old age, hypoactivity due to underlying Parkinsonism and relatively small amount of shunt flow, medical therapy was chosen. The patient remained asymptomatic for 10 months after discharge without intervention.

Coronary artery fistula

Although coronary arterial fistula is rare, it is one of the most common among the coronary artery anomalies. Coronary arterial fistula most commonly affects the right side of the heart. It may occur isolated or along with congenital heart diseases. Angiography remains the best investigation for diagnosing the disease. Unless very large and hemodynamically significant, it is usually asymptomatic in younger patients. With increasing age, symptoms begin to appear, and the incidence of complication rises. Treatment by transcatheter or surgical closure gives the best results, provided this is performed early in the course of the disease. This review was prepared by searching the terms "coronary artery fistula," "coronary cameral fistula," "surgical management of coronary arterial fistula," "MDCT in coronary artery fistula," and "multiple coronary artery fistulae" in Google Scholar, PubMed, and PubMed Central and exploring the related articles shown on the side of page.