Coronary artery fistulas: a single-center case series

Introduction

Coronary artery fistulas (CAFs) are rare anomalous connections between a coronary artery and a major vessel or cardiac chamber. Currently they are being increasingly encountered due to the more widespread use of various imaging modalities and coronary angiography. Although the vast majority of CAFs are incidentally diagnosed and have no clinical relevance, they can cause significant morbidity such as myocardial infarction, congestive heart failure and endocarditis.

Methods

A consecutive series of 55867 coronary arteriograms performed in our Cardiology Department from 2007 to 2019 was retrospectively investigated for the presence of coronary artery fistulas. Patients clinical, angiographic and therapeutic data up to november 2019 were analyzed. Data were obtained from medical records of hospital stay and subsequent consultations.

Results

We identified 50 patients who were diagnosed with one or more CAFs, with ages between 5 and 85 years (mean 59 years). 62% (n=31) were males.

The great majority of patients had a single fistula (n=34, 68%), 11 patients had two fistulas (22%), 1 patient had 3 fistulas (2%) and 4 patients had multiple fistulas (8%).

CAFs arose more frequently from the left anterior descending artery (n=27), followed by the right coronary (n=18), left circumflex (n=15), left main (n=5) and intermediate artery (n=2). The most frequent drainage site was the pulmonary artery (n=38).

The majority of CAFs were incidentally found (n=32; 64%) and thought to have no significance for the patients' clinical status. As for the rest of the patients, CAFs were diagnosed during evaluation of: a heart murmur (n=7); exertional chest pain with no associated significant atherosclerotic coronary artery disease (n=7); exertional dyspnea (n=2); positive exercise stress test (n=1); NSTEMI and cardiac arrest (n=1).

Regarding treatment, watchful waiting was the main approach (n=40; 80%). 3 patients had their CAFs closed during surgery for another heart condition (CABG/aortic valve replacement). In 1 patient, heart surgery was specifically conducted for fistula closure. 6 patients (12%) underwent fistula transcatheter closure.

Conclusion

CAFs are rare coronary anomalies and the majority has no clinical relevance, so watchful waiting is the commonest approach. When they are hemodynamically significant or symptoms/complications arise, surgical or transcatheter closure should be considered. This study describes the angiographic, clinical and therapeutic data of CAFs detected along the last 12 years in a single tertiary care center catheterization laboratory.

Funding Acknowledgement

Type of funding source: None

P1310 Prosthetic valve endocarditis or thrombus?

One cause of constitutional syndrome in patients previously submitted to valve replacement surgery is a prosthetic endocarditis; this occurs in 1-6% of valve surgeries and has an adverse prognosis. Although this is a likely etiology, it is important to keep other possibilities in mind. This clinical case is about a 61 years old male, with known history of smoking, atrial fibrillation anticoagulated with warfarin (with low TTR), and rheumatic fever in childhood, with severe aortic stenosis/regurgitation and moderate mitral regurgitation. In August 2018 he was admitted in our hospital with mitral valve endocarditis cause by Streptococcus agalactiae. He was submitted to an aortic and mitral valve replacement surgery with 2 bioprothesis. Three months later he was admitted again with weight loss, fatigue, dyspnea for small efforts and worsening anemia. The first diagnosis hypothesis was prosthetic endocarditis. The echocardiogram showed normo-functioning aortic bioprothesis; obstructive mitral bioprothesis with an image suggestive of a vegetation; and a de novo mass in the left auricle, compatible with a thrombus. This clinical case was discussed in Heart Team: as the patient was clinically stable, it was opted for an initial conservative approach; although there was a strong clinical suspicion that all the clinical case was due to thrombotic manifestations (assuming that the vegetations had a non-infectious origin), he was nonetheless medicated with vancomycin, gentamicin and rifampicin, as the diagnosis of early culture negative prosthetic endocarditis could not be discarded. He was anticoagulated with enoxaparin. In the reevaluation echocardiogram there was a significative reduction of the left atrial thrombus and disappearance of the mitral valve vegetation image, with improvement of the mitral valve prosthetic gradients. The case was discussed again in Heart Team: due to the clinical evolution, the hypothesis that this was all caused by a thrombotic manifestation grew stronger; it was opted not to submit the patient to a new surgery and the antibiotic therapy was suspended. To study the pro-thrombotic state and the constitutional syndrome, a full body CT was requested: "hilar-mediastinal and bilateral hilar adenopathy; right supraclavicular adenopathy; splenomegaly with infarcted area." The right hilar adenopathy was biopsied; the pathologic exam revealed non-small cells lung carcinoma. The patient was discharged, medicated with warfarin and oriented to outpatient Oncology consult. Any cancer can be associated with thrombotic manifestations. In this case, considering the heavy smoking burden, lung cancer is one of the first etiologies to consider. The thrombotic manifestations of the non-small cells lung carcinoma are due to a paraneoplastic mechanism and might precede the cancer diagnosis. This clinical case highlights the importance of thinking of different etiologies in the differential diagnosis of a constitutional syndrome.

Abstract P1310 Figure. Left auricle mass

Sea bass sperm freezability is influenced by motility variables and membrane lipid composition but not by membrane integrity and lipid peroxidation

Cryopreserved sperm quality depends on the characteristics of fresh sperm. Thus, it is necessary to establish a group of variables to predict the cryopreservation potential of the fresh samples with the aim of optimizing resources. Motility, viability, lipid peroxidation and lipid profile of European sea bass (Dicentrarchus labrax) sperm were determined before and after cryopreservation to establish which variables more accurately predict the sperm cryopreservation potential in this species. Cryopreservation compromised sperm quality, expressed as a reduction of motility (46.5 ± 2.0% to 35.3 ± 2.5%; P<0.01) and viability (91.3 ± 0.7% to 69.9 ± 1.6%; P<0.01), and produced an increase in lipid peroxidation (2.4 ± 0.4 to 4.0 ± 0.4 μmoles MDA/mill spz; P<0.01). Also, significant changes were observed in the lipid composition before and after freezing, resulting in a reduction in the cholesterol/phospholipids ratio (1.4 ± 0.1 to 1.1 ± 0.0; P<0.01), phosphatidylcholine (47.7 ± 0.8% to 44.2 ± 0.8%; P<0.01) and oleic acid (8.7 ± 0.2% to 8.3 ± 0.2%; P<0.05) in cryopreserved sperm, as well as an increase in lysophosphatidylcholine (4.4 ± 0.3% to 4.8 ± 0.3%; P<0.01) and C24:1n9 fatty acid (0.5 ± 0.1% to 0.6 ± 0.1%; P<0.05). Motility, velocity, cholesterol/phospholipids ratio, monounsaturated fatty acids and the n3/n6 ratio were positively correlated (P<0.05) before and after freezing, whereas, viability and lipid peroxidation were not correlated. Motility and the cholesterol/phospholipids (CHO/PL) ratio were negatively correlated (P<0.05) with each other and the CHO/PL ratio was positively correlated (P<0.05) with lipid peroxidation. Therefore, the results demonstrated that motility and plasma membrane lipid composition (CHO/PL) were the most desirable variables determined in fresh samples to predict cryo-resistance in European sea bass sperm, taking into account the effect of both on cryopreserved sperm quality.