Angina and ischemic electrocardiographic changes secondary to coronary arteriovenous fistula with abnormal basal and reserve coronary blood flow

Coronary-to-pulmonary artery fistula in adults: Evaluation with thallium-201 myocardial perfusion SPECT

Objectives

With the increasing use of multi-detector CT, the number of detected cases with coronary-to-pulmonary artery fistula (CPAF) has increased. Several previous studies reported severe cases of angina, but no appropriate tests to evaluate myocardial perfusion for patients with CPAF have been established. We evaluated the hemodynamic characteristics of CPAF using thallium-201 (Tl-201) single photon emission computed tomography (SPECT).

Materials and methods

Tl-201 SPECT was performed in 17 patients with CPAF, but without evidence of coronary artery disease on coronary computed tomography angiography (CCTA) (age, 58.5±13.3 years; 8 men). Quantitative analysis of scintigraphic data was performed. Additionally, perfusion abnormalities were compared with CCTA findings. Medical records were obtained to define clinical data, diagnostic findings, symptoms, management, follow-up data, and major adverse cardiac events (MACE).

Results

Six patients (35.2%) showed perfusion abnormalities on SPECT studies and could be classified as follows: 3 patients, no reversible ischemia (3/17, 17.6%); 1 patient, mild ischemia (1/17, 5.8%); and 2 patients, moderate ischemia (2/17, 11.7%). During the follow-up, ten patients (58.8%) improved under medical management and 5 patients (29.4%) underwent surgical ligation for CPAF with symptomatic improvement in 4 patients. Seven patients performed follow-up myocardial perfusion SPECT, and symptomatic improvement correlated well with scintigraphic perfusion improvement in 6 patients No MACE was observed.

Clinical significance

Tl-201 myocardial perfusion SPECT might be useful for determining the hemodynamic status and for risk stratification in patients with CPAF.

Congenital coronary artery fistulas complicated with pulmonary hypertension: Analysis of 211 cases

AIM

To compare the behavior of pulmonary hypertension (PHT) associated with coronary artery fistulas (CAFs) between the Asian and Caucasian subjects.

METHODS

CAFs may be complicated with PHT secondary to left-to-right shunt. Literature review limited to the English language. A total of 211 reviewed patients were collected. Of those, 111 were of Asian and 100 were of Caucasian ethnic origin. The mean age of the Asian and the Caucasian groups of patients were 48.9 (range 19-83) and 49.9 years (range 16-85), respectively. In both groups, right heart catheterization was the most commonly (95%) used method for determining pulmonary artery pressure.

RESULTS

From all of the reviewed subjects, PHT was found in 49 patients (23%), of which 15 were Asian and 34 were Caucasian. In 75% of PHT subjects, mild to moderate PHT was reported and 76% of the fistulas had a vascular mode of termination. Treatment was surgical in 61%, followed by percutaneous therapeutic embolization (27%) and finally conservative medical management in 12% of PHT subjects. PHT was associated with a slight female gender predominance. The majority demonstrated mild to moderate PHT. PHT was reported more frequent in the Caucasian compared with the Asian ethnicity group. The majority of fistulas in patients with PHT had a vascular mode of termination. The results of this review are intended to be indicative and require cautious interpretation.

CONCLUSION

The likelihood for a CAF patient to develop PHT is presented when possessing the following features, with a Caucasian female having a fistula with a vascular mode of termination.

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.

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.

Mortality in patients with microvascular disease

Patients with chest pain/ischemic cardiac disease and normal coronary arteriography are thought to have a benign prognosis despite diminished quality of life. Many patients with hypertension fall into this group, at least in the early stage of their disease. Whether abnormalities in coronary flow reserve in these patients are associated with increased morbidity and mortality is unknown. One hundred sixty-eight patients with chest pain/ischemic cardiac disease and normal coronary angiograms who underwent invasive measures of coronary flow reserve were followed longitudinally. Mortality and quality of life were ascertained by query of the national death index and telephone administration of standardized questionnaires. Patient follow-up occurred at a mean of 8.5 years. In the abnormal coronary flow reserve group, 12 deaths (20%) were documented in 60 patients compared with eight out of 108 patients (7%; p=0.016) with normal coronary flow reserve. Coronary flow reserve did not predict impairment in functional health status in long-term follow-up. Thus, invasive measures of coronary flow reserve in patients with chest pain/ischemic cardiac disease and normal coronary angiograms predicted increased mortality. Surviving patients with chest pain/ischemic cardiac disease and normal coronary angiograms have significant morbidity.

Three major coronary artery-to-left ventricular shunts: report of three cases and review of literature

Among the congenital coronary artery fistulas, diffuse fistulation into the left ventricular chamber, usually expressed in terms of a coronary artery-left ventricular shunt, is not as rare today as was previously thought. However, the origin of such a shunt from all three major coronary arteries is rare. This paper reports three cases of such an occurrence and presents the clinical features and management of this rare anomaly by analyzing 31 cases, including 28 from the literature.

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

The physiology of a coronary to pulmonary artery fistula has not been well characterized. This case report demonstrates the flow velocity pattern of a coronary fistula to the pulmonary artery which supports the hypothesized physiology that flow is predominantly continuous without a phasic pattern. The flow velocity within a coronary fistula has not been previously demonstrated.