Characterization of intra-arterial flow velocity within left coronary to pulmonary artery fistula

Percutaneous closure of right coronary to superior vena cava fistula

Coronary artery to superior vena cava (SVC) fistula is a very rare congenital anomaly of the heart. It typically follows the course of sinoatrial-nodal branch. It can originate from the right coronary or circumflex artery. In the majority of cases, it terminates in the SVC close to the right atrium junction. Only five cases were treated in literature successfully through a transcatheter approach. We present a case with a symptomatic right coronary artery to SVC fistula treated with a unique percutaneous embolization using a guidewire loop/balloon occlusion technique. Controlled access and embolization of the fistula was achieved by through-and-through guidewire access across the coronary fistula from the arterial groin access to the venous groin access with balloon occlusion of the coronary artery fistula while detachable coils were positioned.

Sequential moderate coronary artery fistula and moderate coronary artery stenosis causing ischemia demonstrated by fractional flow reserve and relieved following percutaneous coronary intervention

Coronary artery fistulae are rare anomalous connections arising from the coronary circulation. We report a case of anterior wall myocardial ischemia caused by the combination of sequential coronary-to-pulmonary artery fistula and moderate (50-60%) stenosis of the left anterior descending coronary artery. Ischemia was demonstrated by myocardial stress perfusion imaging as well as fractional flow reserve. Percutaneous coronary intervention of the lesion resulted in resolution of ischemia.

Predictors of Long-Term Adverse Outcomes in Patients With Congenital Coronary Artery Fistulae

Background— Significant morbidities, including angina, symptomatic heart failure, and myocardial infarction, have been reported after coronary artery fistula (CAF) closure; however, predictors that may be associated with adverse outcomes have not been established. The goal of this investigation is to describe the long-term outcomes witnessed in patients with either treated or untreated CAF at our institution and to investigate whether certain features predicted adverse outcomes.

Methods and Results— The records and angiograms of patients with CAF who underwent a diagnostic cardiac catheterization at Children’s Hospital Boston from 1959 through 2008 were reviewed. Of 76 patients identified, 20% were associated with additional congenital heart disease. Forty-four underwent transcatheter closure, 20 underwent surgical repair, and no intervention was performed in the remaining 12 subjects. Three patients who had initially undergone surgical closure had a second intervention, 1 underwent repeat surgery, and 2 underwent transcatheter closure. One patient who had undergone transcatheter closure underwent a second transcatheter closure for residual fistula. Major complications, including myocardial infarction, angina with coronary thrombosis, and symptomatic cardiomyopathy, occurred in 11 (15%) patients. The sole angiographic feature that was predictive of adverse outcome was drainage of the CAF into the coronary sinus ( P <0.001). Clinical predictors associated with adverse outcomes included older age at diagnosis ( P <0.001), tobacco use ( P =0.006), diabetes ( P =0.05), systemic hypertension ( P <0.001), and hyperlipidemia ( P <0.001).

Conclusions— Long-term complications of CAF closure may include coronary thrombosis, myocardial infarction, and cardiomyopathy. CAF that drain into the coronary sinus are at particularly high-risk of long-term morbidities after closure, and strategies including long-term anticoagulation should be considered.

Solitary coronary artery fistulas: a congenital anomaly in children and adults. A contemporary review

Congenital solitary coronary artery fistulas (CAFs) in adults are uncommon anomalies, which by themselves may resemble the whole spectrum of cardiac presentations from asymptomatic behavior to life-threatening and catastrophic events with syncope or shock and even sudden death. It may take decades to collect a reasonable series of patients in adults and children. From the literature between 1993 and 2004, 236 patients with CAFs were considered for evaluation. The present review is intended to assist cardiologists who are unfamiliar with congenital CAFs in adults by suggesting clues for decision making regarding diagnosis and management. Dyspnea and chest pain represented a frequent 91/128 (71%) clinical symptom in CAFs in adults while in the pediatric age group the majority were silent 105/133 (79%) and dyspnea and chest pain accounted for only 8% of the symptoms. The diagnostic modalities were mainly cardiac catheterization and coronary angiography. On the other hand, in the pediatric patients, echocardiography and coronary angiography mainly guided the diagnosis. Regarding treatment strategy in the reviewed subjects, percutaneous transluminal embolization was performed in 18% of the pediatric and in only 5% of the adult subjects. Surgical ligation (46% vs. 38%) and conservative medical strategies (36% vs. 24%) were reported in both pediatric and adult groups. Presentations of CAFs vary considerably in both groups. These differences include the diagnostic modalities, spontaneous closure, spontaneous rupture, and management. From this review, it seemed that--but it may be biased--surgical ligation remains the major mainstay for closure of CAFs in adult and pediatric populations. Recommendations are necessary for antibiotic prophylaxis and antiplatelet and/or anticoagulant therapy for prevention of endocarditis and thrombotic events in patients with CAFs associated with coronary artery dilatation or aneurysmal formation of the fistulous tract.

Coronary artery fistula: single-center experience spanning 17 years

BACKGROUND

Coronary artery fistula (CAF) is an uncommon form of congenital heart disease. It is often diagnosed incidentally during angiograms. We have reported on clinical characteristics, diagnosis, and management of CAF.

METHODS

Retrospective review of a tertiary referral institution's database identified 30 patients with CAF between 1987 and 2004. Mean follow-up was 31.61 +/- 48.03 months.

RESULTS

Mean age was 60 +/- 12.7 years. Most common site of CAF origin was the left anterior descending artery (LAD) (14, 46.7%). The most common site of drainage was the main pulmonary artery (15, 50%). Therapeutic strategies were based on symptoms and shunt size. Conservative management was the option in 17 patients (56.7%) with small shunts and mild or no symptoms. Patients with moderate/severe symptoms and/or large shunts were treated with either percutaneous embolization (6, 20%) or surgical ligation (7, 23.3%). Four patients (13.3%) died during follow-up. No deaths were reported in the embolization group, two patients died of cancer in the conservative management group, and two patients died in the surgical group due to cardiac tamponade and cancer, respectively.

CONCLUSIONS

Origin of CAF was predominantly from the left system. Clinical presentations were variable depending on type, size of fistula, and the presence of other cardiac conditions. Management of CAF is still controversial and treatment of adult asymptomatic patients with nonsignificant shunting is still a matter of debate. Newer imaging modalities may enhance noninvasive diagnosis. A national registry is necessary for further insights into optimal treatment for large fistulae and the natural history of smaller fistulae.

Minimally invasive sternotomy for ligation of congenital bilateral coronary artery to pulmonary artery fistulae: a case report

Coronary artery fistulae (CAF) are the second most common type of anomalies of the coronary arteries, after anomalies of origin. We hereby present a rare case of bilateral coronary to pulmonary artery fistulae discovered incidentally in an asymptomatic young man, with abnormal electrocardiographic findings on routine examination. The fistulae were successfully ligated with a minimally invasive approach, which to our knowledge has not been previously reported.

Dutch survey of coronary artery fistulas in adults: Congenital solitary fistulas

AIMS

Congenital coronary artery fistulas are frequently identified in adult and pediatric populations and they have been associated with various clinical and morphological features. The purpose of this study was to define the clinical and coronary angiographic morphological characteristics of adult patients with congenital solitary CAFs in the Dutch Registry.

METHODS AND RESULTS

Fifty-one patients with angiographically documented CAFs were reviewed for clinical evaluation, used non-invasive and invasive diagnostic tools and treatment modalities. Unilateral CAFs were predominant (80%) and 84% of the patients were symptomatic. The most common presenting symptom was angina pectoris (57%). Angina pectoris was present in a quarter of the patients in the absence of coronary artery disease (CAD). Significant CAD was present in 49% of the patients. Twenty-nine percent of the CAFs showed aneurysmal formation, underlying their potential hazard of rupture. Myocardial infarction occurred in 18% of the patients. In 27% of CAFs multiplicity of the origin was found and nearly all fistulas were tortuous (97%). Treatment modalities were conservative medical in 70%, percutaneous transluminal embolisation in 5% and surgical ligation in 25% of the cases. Multiple micro-fistulas from the coronary arteries to the left ventricle were excluded from the study.

CONCLUSION

In this national survey series, congenital solitary CAFs can be presented with typical angina pectoris in the absence of obstructive CAD. Fistula-related coronary artery was infrequently involved in the development of ipsilateral myocardial infarction. Tortuousity and multiplicity of the CAFs may determine, for the individual patient, the choice of the currently available treatment modalities.