Silent left coronary artery-cameral fistula: probable cause of myocardial ischemia

Congenital coronary artery-left ventricular multiple micro-fistulas and hypertrophic cardiomyopathy: a case report and literature review

Background

Coronary artery-left ventricular multiple micro-fistulas (CA-LVMMFs) is a rare congenital vascular anomaly that may present with no obvious clinical symptoms or a typical angina attack. CA-LVMMFs is usually found unexpectedly during coronary angiography (CAG).

Case presentation

We report a case of a 65-year-old man admitted to the hospital with acute coronary syndrome. CA-LVMMFs was found during coronary angiography. Echocardiography showed apical hypertrophy and blood flow signals were seen in the apical myocardium, connected with the left ventricle. We searched the MEDLINE database and found 39 relevant reports. We made statistics on the clinical characteristics of these patients and found half involved hypertrophy or perfusion defects in the ventricular septum or apex.

Conclusion

As a rare congenital anomaly, the effect of CA-LVMMFs on patients is unclear. By reporting a case and summarizing literature reports, we found that CA-LVMMFs may be associated with myocardial hypertrophy, especially ventricular septal and apical hypertrophy.

Bilateral coronary artery fistulas communicating with main pulmonary artery and left ventricle: case report

Coronary artery fistula is an uncommon congenital malformation that generally drains into the main pulmonary artery or the right side of the heart. This is a case report on bilateral coronary artery fistulas communicating with the main pulmonary artery and the left ventricle. A 65-year-old woman was investigated for recurrent chest pain. Coronary angiography revealed this anomalous coronary artery connection without evidence of atherosclerotic coronary artery disease. The rarity of coronary artery fistulas involving both the main pulmonary artery and the left ventricle is emphasized.

Three major coronary artery-to-left ventricular fistula: an unusual cause of a diastolic murmur at the apex

Coronary artery fistula involving all the 3 major coronary arteries and emptying into the left ventricle is rare. We report an asymptomatic patient with coronary artery fistula from the 3 major coronary arteries communicating with the left ventricle, who presented with a diastolic murmur at the apex.

Right coronary artery aneurysm with fistula to left ventricle: multislice CT appearance

A 34-year-old male presented with prior radiographic evidence of enlargement of the right side of the heart. ECG-gated enhanced multislice CT was performed. Axial source images revealed a diffuse, hugely enlarged right coronary artery (RCA) aneurysm. The distal portion of the RCA flowed directly into the left ventricle (LV), suggesting an RCA to LV fistula. 3D volume rendered images clearly revealed a huge, enlarged RCA aneurysm from the proximal, mid, and distal portions of the RCA. The distal portion of the RCA aneurysm disappeared abruptly without showing distal branching, also suggesting an RCA to LV fistula.

Dutch survey of congenital coronary artery fistulas in adults

AIMS

This Dutch survey focused on the clinical presentation, noninvasive and invasive diagnostic methods, and treatment modalities of adult patients with congenital coronary artery fistulas (CAFs).

METHODS

Between 1996 and 2003, the initiative was taken to start a registry on congenital CAFs in adults. In total 71 patients from a diagnostic coronary angiographic population of 30,829 at 28 hospitals were collected from previously developed case report forms. Patient demographic data, clinical presentation, noninvasive and invasive techniques and treatment options were retrospectively collected and analysed.

RESULTS

Out of 71 patients with angiographically proven CAFs, 51 (72%) had 63 congenital solitary fistulas and 20 (28%) had 31 congenital coronary-ventricular multiple microfistulas. Patients with pseudofistulas were excluded from the registry. Coronary angiograms were independently re-analysed for morphology and specific fistula details. The majority (72%) of the fistulas were unilateral, 24% were bilateral and only 4% were multilateral. The morphological characteristics of these 94 fistulas were as follows: the origin was multiple in 47% and single in 53%; the termination was multiple in 52% and single in 48%; and the pathway of the fistulous vessels was tortuous/multiple in 66%, tortuous/single in 28%, straight/multiple in 3% and straight/single in 3%. Percutaneous transluminal embolisation (PTE) was performed in two (3%) patients; surgical ligation was undertaken in 13 (18%) patients. The overwhelming majority of the patients (56; 79%) were treated with conservative medical management. The total mortality was 6% (4/71) at a mean follow-up period of approximately five years. Cardiac mortality accounted for 4% (3/71); in all three patients, death could possibly be attributed to the presence of the fistula.

CONCLUSION

Registry of congenital coronary artery fistulas in adults in the Netherlands is feasible. In spite of restrictions imposed by the Dutch Privacy Law, it was possible to include 71 adult patients with congenital coronary artery fistulas who were eligible for thorough evaluation.

Catheter closure of coronary artery fistulas

Coronary artery fistulas are rare and vary widely in their morphological appearance and presentation. This paper presents experience of catheter closure of coronary artery fistulas in 40 patients. Catheter closure was performed with a variety of techniques, including detachable balloons, stainless steel coils, controlled-release coils, controlled-release patent ductus arteriosus (PDA) coils, and Amplatzer PDA plug. The vast majority of the fistulas were occluded with coils and in particular, controlled-release coils. Successful occlusion of the fistula was achieved in 39 (97%) of 40 patients. In one patient, the detachable balloon deflated prematurely and the patient underwent elective surgery. One 4-month-old infant died approximately 6 hours after the procedure. Immediate occlusion of the coronary artery fistula occurred in 33 (82%) of patients and late occlusion in 4 patients. Thus overall, total occlusion was achieved in 37 (97%) of 39 patients. The main complication was embolization of the occlusion device, which occurred in 6 (17%) of cases. In one of these cases, a detachable balloon deflated prematurely, and in five patients, coils embolized and were retrieved. In one of the patients, all six coils embolized 24 hours after the procedure but were retrieved, and further coils were implanted successfully. Controlled-release coils have made an important contribution to the technique of catheter closure of coronary artery fistulas. Catheter closure of these fistulas is an acceptable alternative to the standard surgical treatment.

Death related to coronary artery fistula after rupture of an aneurysm to the coronary sinus

Large coronary fistulas are considered to cause myocardial ischemia due to diversion of the coronary blood flow. In this case the authors report the reverse effect--the spontaneous closure of a large fistulation between the left circumflex artery and the coronary sinus evoked angina pectoris in a middle aged man, who died several years later. Postmortem examination revealed a coronary aneurysm that had ruptured and dissected into the coronary sinus and finally thrombosed. The origin of the aneurysm could be congenital but perhaps also represents a healed stage of Kawasaki disease.

Left coronary artery-left ventricle fistula with right coronary artery spasm

A 72-year-old woman was admitted to our hospital for evaluation of chest pain. Coronary angiography showed a left coronary artery-left ventricle fistula. An acetylcholine provocation test induced vasoconstriction of the right but not the left coronary artery. Her chest pain was not relieved by combined therapy with isosorbide dinitrate, diltiazem and nicorandil. Because of the coronary spasm, beta-blockers could not be used. However, her chest pain was relieved after the administration of a minor tranquilizer. Thus, the patient's chest pain was unlikely to be associated with either the fistula or the coronary spasm.

Myocardial ischemia and infarction due to multiple coronary-cameral fistulae: two case reports and review of the literature

The functional significance of coronary-cameral fistulae, and the effect of these arterial anomalies upon effective coronary blood flow, continue to be debated. Two cases of coronary cameral fistulae, each of which illustrates the likelihood of an ischemic substrate, are herein presented, along with a review of the relevant literature regarding this disorder.

Coronary arterioluminal communications in routine angiography

Visualization of the left ventricular cavity from coronary arterioventricular communications is rarely encountered in routine coronary angiography. We report 14 patients, of 5,500 consecutive cardiac catheterizations, in whom these communications were evident during coronary angiography. All 14 patients had angina pectoris; in each the arterioluminal communication originated from the left anterior descending coronary artery. Two patients had evidence of anterior wall ischemia despite a normal left anterior descending coronary artery, suggesting that a possible steal phenomenon is responsible for the myocardial ischemia.

Coronary artery fistula in children and adults: a review of 25 cases with long-term observations

We studied 25 patients with coronary artery fistula between 1976 and 1994. Age ranged from 1 to 58 years. Twelve patients were symptomatic; seven had dyspnoea, four had angina, one had palpitation and one had syncope. Coronary arteries in four. Coronary artery fistula drained into right ventricle in 11, right atrium in nine, pulmonary artery in four and left ventricle in two. The Qp/Qs ranged from 1.0 to 2.6 with a mean of 1.39 +/- 0.38. Five patients had associated cardiac anomalies. Two had atrial septal defects, one had patent ductus arteriosus, one had atresia of proximal right coronary artery and in one patient, the right coronary was arising from left coronary artery. Five patients underwent surgery without any operative mortality. Thirteen patients were followed-up medically for a mean period of 6.1 +/- 5.1 years. There were no complications related to coronary artery fistula during follow-up. In one patient coronary artery fistula closed spontaneously.

Left and right coronary artery to left ventricular fistula: demonstration of myocardial ischemia by treadmill test and Holter monitoring--a case report

Fistulous communication from the coronary artery to the left ventricle is extremely rare. The authors report such a case in a sixty-year-old woman with chest pain. They demonstrated myocardial ischemia on treadmill test and Holter monitoring in this patient.

Case report: a case of multiple coronary artery to left ventricular communications

A 39-year-old man with anginal pain had multiple coronary artery to left ventricular communications. His electrocardiogram showed evidence of left ventricular hypertrophy, and an echocardiogram revealed a dilated left ventricle. A coronary angiogram revealed multiple coronary artery to left ventricular fistulae involving three major coronary arteries with no evidence of atherosclerotic lesions. Only 17 cases of such fistulous communications involving three major coronary arteries have been reported in the literature. It is suggested that the fistulous communications to the left ventricle was a cause of his angina pectoris, probably because of the coronary steal phenomenon.

The detection of myocardial ischemia by thallium-201 myocardial scintigraphy in patients with multiple coronary arterioventricular connections

The question of whether myocardial ischemia could be induced in 5 patients with multiple coronary arterioventricular connections by thallium-201 (201Tl) exercise stress myocardial scintigraphy was investigated. Both ST-T changes on ECG and transient myocardial perfusion defects in myocardial scintigrams were observed in 2 patients (40%). In previous reports, all multiple coronary arterioventricular connections, which were shown in angiograms, have been regarded as either Thebesian veins or embryonic sinusoids. However, it is unlikely that Thebesian veins cause myocardial ischemia judging from anatomy. If the vessels cause myocardial ischemia, they should be regarded as multiple coronary arterioventricular fistula. Angiography itself cannot differentiate multiple coronary arterioventricular fistula from Thebesian veins or remnants of embryonic sinusoids. Exercise stress myocardial scintigraphy has a high potential to detect myocardial ischemia due to intracoronary steal. Exercise stress myocardial scintigraphy was used to demonstrate myocardial ischemia in multiple coronary arterioventricular connections. It is concluded that exercise stress myocardial scintigraphy is a reliable test to differentiate multiple coronary arterioventricular fistula from Thebesian veins or remnants of embryonic sinusoids in clinical practice.

Asymptomatic left and right coronary artery-left ventricular fistula in an elderly patient with a diastolic murmur only

A 62-year-old woman who had a diastolic murmur was found to have an unusual type of coronary arterial fistula between bilateral coronary arteries and the left ventricle by selective coronary angiography. This anomaly appeared to be of no functional significance. The diastolic murmur was the only audible sign of the fistulous communications in this case.

Myocardial infarction due to multiple coronary-ventricular fistulas

Coronary-ventricular fistulas have been described in both right and left coronary arteries and have been implicated in causing cardiac symptoms and coronary ischemia. We present a case of three-vessel coronary-ventricular fistulas emptying into both ventricles, associated with a left-to-right shunt and a myocardial infarction.

Normal and anomalous coronary arteries: definitions and classification

Results of a comprehensive survey of the literature concerning coronary artery anatomy, embryology, and pathophysiology show the lack of an adequate definition of normal coronary arteries. To fill this gap, the present review considers the available data concerning the embryogenesis of the coronary arteries and proposes a new definition of normality that refers to essential anatomic features. The concepts of normal variant versus anomaly are introduced, based on a statistical definition of the normal range (99% of the presentations observed in a normal, unselected population). Coronary anomalies are defined as those patterns found in less than 1% of the cases. The wide spectrum of coronary abnormalities is then organized according to a comprehensive classification scheme. For clinical purposes the conceptual difference between anatomic and pathophysiologic anomalies is stressed. The current paucity of experimental studies concerning normal and abnormal embryogenesis of the coronary arteries is found to be the major limitation to an understanding of this subject.

Early and late results of surgical treatment of congenital coronary artery fistula

The early and late results of surgical treatment in 23 patients with congenital coronary artery fistula (CCAF) are presented. One patient died for reasons unrelated to the fistula during corrective surgery for an associated complex cyanotic abnormality. The patients with isolated CCAF and preoperative symptoms improved significantly after surgical closure of the CCAF (p less than 0.05). We conclude that all symptomatic patients with CCAF should be treated with surgical closure of the fistula.

Diffuse coronary artery to left ventricular communications: an unusual cause of demonstrable ischemia

Diffuse communications between both the left and right coronary arteries and the left ventricle were found in a 46-year-old man presenting with typical angina pectoris. Symptoms were reproducible on treadmill exercise and ST segment depression, and redistribution septal defects were documented on stress Thallium scintigraphy. Antianginal drugs were effective in treating the patient's symptoms. Only 13 patients with similar anatomy have been previously described. This report is the first to document reproducible objective evidence of ischemia in such patients. The literature is reviewed and possible mechanisms of ischemia and its treatment discussed.