Percutaneous approaches to closure of coronary artery fistulas

Transcutaneous closure of a huge multilocular coronary to right atrium fistula causing severe right side heart failure: A case report

Coronary artery fistula (CAF) is a congenital connection between a coronary artery and cardiac chambers, or a vessel bypassing a capillary system. The clinical presentation of congenital CAF varies, depending on its size and the draining chamber. A 40-year-old female presented with right-sided heart failure and was diagnosed by transthoracic echocardiography and computed tomography with 3D printing to have substantial coronary to right atrium fistula. Left main artery was cannulated to the outlet of the fistula at the base of the superior vena cava to the right atrium. The wire snared and created the arterio-venous loop. A 7F delivery sheath through the arterio-venous loop landed in proximal left circumflex part of the fistula, Amplatzer duct occluder I size 12/10 selected with the distal (aortic) skirt positioned distal to the most distal visible coronary branch. We waited for 10 min monitoring the ST segments for any changes. Finally, the device was released with complete closure of the fistula sparing all coronary branches. Follow-up transthoracic echocardiography after six months showed no flow to fistula sacs; the patient's symptoms improved dramatically. In conclusion, transcatheter closure of an isolated enormous multiloculated CAF is feasible and relatively safe. Surgery should be reserved for CAF with failed percutaneous closure. <Learning objective: Coronary artery fistula (CAF) is a congenital connection between a coronary artery and cardiac chambers, or a vessel bypassing a capillary system. Closure of CAF is indicated for symptomatic patients or asymptomatic patients with huge fistulas. Transcatheter closure approaches are considered an alternative to surgical correction with proven efficacy and safety, with similar morbidity and mortality. Surgery should be reserved for CAF with failed percutaneous closure.>.

Transcatheter occlusion of giant congenital coronary cameral fistulae: a case series

BACKGROUND

A coronary cameral fistula is a rare connection between a coronary artery and a cardiac chamber or vein bypassing the cardiac capillary bed system. Most of these fistulae are congenital and solitary, although they can be acquired and multiple.

CASES PRESENTATION

Case 1: A 10-year-old black South African boy presented with a long-standing history of fatigue; he had a heart murmur, and a bounding pulse and wide pulse pressure. An echocardiogram demonstrated a large coronary cameral fistula involving his left coronary artery and his left ventricle. This was also confirmed on ascending aortogram. Surgical ligation was done and his symptoms improved afterward, but a small residual fistula remained. Case 2: A 7-year-old black South African boy had decreased effort tolerance and a heart murmur on the mid-sternal border. He had cardiomegaly on chest roentgenogram and a dilated left coronary artery origin on echocardiogram. An ascending aortogram confirmed a large left coronary cameral fistula draining to the left ventricle. Case 3: A 28-year-old black South African woman with decreased effort tolerance and chest pain on exertion had a continuous murmur over the lower sternal border. Echocardiography demonstrated a dilated right coronary artery with a fistulous connection to her right ventricle. An ascending aortogram demonstrated a tortuous coronary cameral fistula arising from her right coronary artery to her right ventricle. All three patients were successfully treated percutaneously using the Amplatzer vascular plug type II device.

CONCLUSION

The availability of numerous vascular closure devices has made transcatheter occlusion the treatment of choice for the majority of coronary cameral fistulae, rather than the traditional surgical ligation.