Shunts between the coronary and pulmonary arteries with normal origin of the coronary arteries

Unilateral and multilateral congenital coronary-pulmonary fistulas in adults: clinical presentation, diagnostic modalities, and management with a brief review of the literature

BACKGROUND

Congenital coronary-pulmonary fistulas (CPFs) are commonly unilateral, but bilateral and multilateral fistulas may occur. In multilateral CPFs, the value of a multidetector computed tomography (MDCT) imaging technique as an adjuvant to coronary angiography (CAG) is eminent. The purpose of this study was to describe the clinical presentation, diagnostic modalities, and management of coincidentally detected congenital CPFs.

HYPOTHESIS

Unilateral and multilateral coronary-pulmonary fistulas are increasingly detected due to the wide speard application of multidetector computed tomography which might be a supplementary or replacing to conventional coronary angiography.

METHODS

We evaluated 14 adult patients with congenital coronary artery fistulas (CAFs) who were identified from several Dutch cardiology departments.

RESULTS

Fourteen adult patients (5 female and 9 male), with a mean age of 57.5 years (range, 24-80 years) had the following abnormal findings: audible systolic cardiac murmur (n = 4), chronic atrial fibrillation (n = 2), nonsustained ventricular tachycardia (n = 1), and cardiomegaly on chest x-ray (n = 2). Echocardiography revealed normal findings with trivial valvular abnormalities (n = 9), depressed left ventricle systolic function (n = 3), and severe mitral regurgitation and atrial dilatation (n = 2). The findings in the rest of the patients were unremarkable. CAG and MDCT were used as a diagnostic imaging techniques either alone (CAG, n = 6; MDCT, n = 1) or in combination (n = 7). Single modality and multimodality diagnostic methods revealed 22 fistulas including CPFs (n = 15), coronary cameral fistulas terminating into the right (n = 2) and the left atrium (n = 1), and systemic-pulmonary fistulas (n = 4). Of all of the fistulas, 10 were unilateral, 6 were bilateral, and 6 was hexalateral. (13) N-ammonia positron emission tomography-computed tomography was performed in 3 patients revealing decreased myocardial perfusion reserve.

CONCLUSIONS

CAG remains the gold standard for detection of CPFs. An adjuvant technique using MDCT provides full anatomical details of the fistulas.

Rare coronary anastomoses between the aorta, pulmonary trunk, left coronary artery, and subclavian artery

We report a rare case of coronary anastomoses in an 83-year-old male cadaveric heart. Anomalous vessels arose from the right sinus of the aorta, left main coronary artery, left anterior descending artery, left anterior medial atrial artery, and left subclavian artery. These vessels bifurcated and anastomosed, and finally connected to the pulmonary trunk. The present case is categorized as a multilateral coronary artery fistula in cardiology.

Histopathologic Characteristics of a Coronary-pulmonary Artery Fistula with a Coronary Artery Aneurysm

Here, we report a case of a 59-year-old woman with a coronary-pulmonary artery fistula with a concomitant coronary artery aneurysm, which comprised an anomalous coronary artery originating at the right coronary cusp, an aberrant branch of the left anterior descending artery, and a coronary artery aneurysm draining into the main pulmonary artery. Histopathologically, non-dilated anomalous coronary artery showed the preservation of internal elastic lamina and medial smooth muscle cell phenotype which lacked in the aneurysmal wall. Thus, the disrupted internal elastic lamina and phenotypic change of medial smooth muscle cells might contribute to aneurysm formation in a coronary-pulmonary arterial fistula.

Coronary artery fistula associated with Kawasaki disease

BACKGROUND

The aim of this study was to investigate the rate, risks factors, and clinical impact of coronary artery fistula (CAF) in Kawasaki disease (KD).

METHODS

From February 1999 to December 2007, a total of 325 pediatric patients fulfilled the diagnostic criteria of KD and admitted for intravenous immunoglobulin treatment were enrolled in this study. Patients with and without CAF were designated as group 1 and group 2, respectively. Patients of group 1 were further subdivided as with and without coronary artery lesions (CALs). The clinical presentations, laboratory data, and outcomes were compared among the groups.

RESULTS

The mean age of the 325 patients was 21.1 months. Group 1 had 17 patients, and group 2 had 308 patients. The rate of CAF in KD was 5.3%. There were significant differences between group 1 and group 2 patients regarding age (11.8 +/- 1.8 vs 21.5 +/- 1.2 months, P = .01), the presence of CAL (64.7% vs 25%, P < .01), white blood cell counts (16.4 +/- 1.3 vs 13.5 +/- 0.3 x 10(3)/mm(3), P = .01), and platelet counts (432.1 +/- 39.1 vs 346.4 +/- 8.4 x 10(3)/mm(3), P = .02). Spontaneous closure of CAF was observed in 7 (41%) of the 17 patients during follow-up (mean 45 months). Group 1 patients without CAL had a more benign clinical course (total fever day 5.8 +/- 0.6 vs 8.6 +/- 0.8, P = .03) and higher spontaneous closure rate (5/6 vs 2/11, P = .035) than patients with CAL.

CONCLUSIONS

Patients of young age, CAL, high white blood cell counts, and high platelet counts have higher rate of CAF formation. Approximately 5% KD patients may associate with CAF, but most of them have good clinical outcome during follow-up.

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.

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 artery fistulae without audible murmur in adults

Retrospective analysis of 4886 adults undergoing coronary arteriography for evaluation of angina between October 1988 and December 1991, revealed coronary artery fistulae in eight patients (all men, aged 36-69 years). No murmur was audible in any of these eight patients. Associated significant coronary artery disease was detected in five patients. The feeder arteries to the fistula were both the left main coronary artery and the left anterior descending artery (LAD) in two, the LAD in six, and the right coronary artery in two patients. The fistula terminated in the pulmonary artery in seven patients and in the right atrium in one patient. Successful operative treatment (coronary artery bypass grafting and ligation of the fistula) was undertaken in four patients with severe obstructive coronary artery disease with satisfactory results. Follow-up for up to 2 years of the three patients with coronary artery fistula and no associated coronary artery disease who did not undergo surgery revealed continuing good prognosis. We conclude that coronary artery fistula in adults is a distinct, though rare (incidence in present series 0.11%) entity, without audible murmur, commonly associated with coronary artery obstructive disease, and that the diagnosis is mostly incidental during routine coronary arteriography.

Bilateral coronary-artery-to-pulmonary-artery fistula coexistent with apical hypertrophic cardiomyopathy--a case report

A sixty-four-year-old man presented with repolarization abnormalities on the electrocardiogram. Echocardiography and cardiac catheterization revealed that he had the rare combination of apical hypertrophic cardiomyopathy with bilateral coronary-artery-to-pulmonary-artery fistula. An exercise thallium scan was negative, suggesting that the marked electrocardiographic changes were most likely secondary to the apical myocardial hypertrophy, instead of to coronary-steal-induced ischemia.

Coronary-pulmonary fistula: long-term follow-up in operated and non-operated patients

Eleven cases with 13, incidentally found coronary-pulmonary fistulous communications were discovered out of about 11,000 diagnostic coronary angiograms performed in different patients, over the period 1968 to 1989. These patients were followed-up for an average period of 4.4 years (range 2-11 years). The majority had a fistulous malformation originating from the proximal part of the left anterior descending artery and terminating in the pulmonary trunk. In three subjects, the right coronary artery participated in formation of the shunt. The fistulas consisted either of a convoluted mass of serpentive vessels, sometimes with aneurysmal formation, or of a solitary single vessel. Angina pectoris, atypical chest pain and fatigue were the most common symptoms. All patients were treated conservatively except one, who underwent ligation of the fistula and coronary arterial bypass grafting. Two subjects are still free of symptoms. No death occurred. None of the patients developed subacute bacterial endocarditis, acute myocardial infarction or left ventricular failure during the period of follow-up of more than four years. Three individuals, prior to the follow-up period, had suffered myocardial infarction contralateral to the shunt. They had no recurrence.

Doppler echocardiographic findings in coronary-pulmonary fistula

We describe a patient with a coronary-pulmonary fistula who had a syncopal attack. He had also pectus excavatum. Doppler echocardiography revealed late diastolic flow in the left high parasternal region which was not caused by pulmonary insufficiency, but by the jet through the fistulous communication. Selective coronary angiography demonstrated the fistula between the left anterior descending artery and the pulmonary trunk.

Type Ia tricuspid atresia with extensive coronary artery abnormalities in a living 22 year old woman

Type Ia tricuspid atresia, with extensive coronary artery abnormalities, is identified in the oldest living patient with this condition, a 22 year old woman. Clinical characteristics include severe cyanosis, effort dyspnea, myocardial infarction in the past and persistent angina pectoris. "Ideal" pulmonary flow and adequate left ventricular function, despite an akinetic apical segment, are substantive factors for this exceptional longevity. Coronary abnormalities consist of: 1) total proximal occlusion of the left anterior descending coronary artery; and 2) partial diversion of coronary artery flow to a segmental pulmonary artery branch. Nonvisualization of the coronary sinus is also noted. Factors other than atherosclerosis may account for total proximal occlusion of the left anterior descending coronary artery. Survival is threatened by adverse effects of ongoing ischemic coronary events.

Radionuclide cardioangiographic demonstration of a coronary artery fistula

A case demonstrating the radionuclide cardioangiographic appearance of a coronary artery fistula is presented. The correct definitive diagnosis of this disorder has generally been made by angiography since clinical findings and noninvasive diagnostic studies can be nonspecific. We report the diagnosis and shunt quantification of a right coronary artery fistula to the right ventricle by radionuclide cardioangiography.

Anomalous origin of the left anterior descending coronary artery from the pulmonary artery

Three children were identified as having anomalous origin of the left anterior descending coronary artery (LAD) from the pulmonary artery (PA). Two had had congestive heart failure in infancy with clinical diagnosis of endocardial fibroelastosis and all had abnormal ECGs. The correct diagnosis was delayed in each case, and two patients required selective coronary angiography. Surgery was accomplished in the three children although ECG abnormalities have persisted and one child has dyskinesis of the left ventricular apex. Because this diagnosis may be difficult to make when intercoronary anastomoses are inadequate to outline the left anterior descending coronary flow into the PA, patients with clinical findings suggestive of anomalous coronary artery may require selective coronary studies to exclude this anomaly.

Surgical management of congenital coronary artery fistulas

Congenital fistulas are the most common of the coronary arterial malformations and with the widespread use of selective coronary arteriography are being recognized with increasing frequency. Twenty-eight patients with congenital coronary fistulas have been evaluated at the Duke University Medical Center between 1960 and 1981. An additional 258 patients have previously been reported in the literature, making a total of 286 available for review. The right coronary artery is most commonly involved, and the fistulous communication is most often to the right ventricle, right atrium or pulmonary artery. Slightly more than half of the patients with coronary fistulas are symptomatic at the time the diagnosis is made. Surgical correction is strongly recommended to prevent the development of congestive heart failure, angina, subacute bacterial endocarditis, myocardial infarction, and pulmonary hypertension, as well as coronary aneurysm formation, with subsequent rupture or embolization. There were no operative or late deaths in the patients who underwent operations. Moreover, there have been no recurrent fistulas during a mean follow-up period of ten years. The risks of operative correction appear to be considerably less than the potential for development of serious and potentially fatal complications, even in asymptomatic patients.

Organized left atrial mural thrombus demonstrated by coronary angiography

Small coronary artery fistulas terminating at the site of adherent, organized mural thrombi in the left atrial appendage were observed during selective coronary angiography in patients with mitral stenosis. The angiographic features of this abnormality can be distinguished from those of cardiac tumors, vascular malformations, and coronary artery fistulas that are not associated with organized thrombus. This coronary angiographic abnormality may indicate the presence of left atrial thrombus that is not revealed by echocardiography and is not manifest clinically by systemic emboli. The size of the collection of radiographic contrast material in the left atrium is not proportional to the size of the thrombus.

Hemodynamically significant primary anomalies of the coronary arteries. Angiographic aspects

Hemodynamically significant primary anomalies of the coronary arteries are those which alter myocardial perfusion. There are four major types: coronary artery fistulae, origin of the left coronary artery from the pulmonary artery, congenital coronary stenosis or atresia, and origin of the left coronary artery from the right sinus of Valsalva, with subsequent passage of the vessel between the aorta and right ventricular infundibulum. The angiographic features of these lesions are discussed.

Atypical progressive angina pectoris caused by a congenital coronary-pulmonary shunt and coronary atherosclerosis

A 57-year-old man with atypical progressive angina caused by congenital coronary-pulmonary shunt and coronary atherosclerosis is described. The angina was rather consistently unresponsive to nitroglycerin. Following closure of the shunt and aortocoronary bypass surgery, the patient became asymptomatic and has remained free of angina 2 year postoperatively. Although the congenital anomaly is rare in adults, it may be considered in the differential diagnosis of atypical angina pectoris, particularly when there is either continuous murmur or systolic murmur over the lower parasternal area.

Anomalous communication of the left coronary artery with a peripheral branch of the right pulmonary artery

A 64-year old man had a history of two myocardial infarctions recurrent episodes of paroxysmal ventricular tachycardia and hemoptysis. Cineangiocardiographic studies showed an anomalous vessel connecting the left coronary artery with a peripheral branch of the right pulmonary artery. Although several coronary obstructive lesions and abnormalities in the distribution of the circumflex branches were found, the anomaly apparently produced a real "pulmonary steal" and, thereby a worsening of the coronary insufficiency. We believe that this is the first reported case in the literature with such a coronary-pulmonary fistula. The angiographic findings are presented in detail, and the possible factors in the development of myocardial ischemia are discussed.

Congenital coronary artery- cardiac chamber fistula. Review of operative management

Eight patients who had surgical correction of coronary artery-cardiac chamber fistula at our center and 163 from a review of the literature are presented. The patients are usually asymptomatic, and the diagnosis is suspected by observing a continuous cardiac murmur. Electrocardiographic findings are nonspecific. Angina pectoris or electrocardiographic evidence of severe ischemia are surprisingly uncommon since coronary artery steal syndrome is also rare. Cardiac catheterization with angiocardiography is required to establish the diagnosis and identify the involved coronary artery and the cardiac chamber into which the fistula terminates. Left-to-right shunt flow is usually low (average Qp/Qs = 1.5). Indications for operation are not precise. If there should be a large shunt flow (2.0) and symptoms of heart failure are present, the decision to operate is clearly justified. This situation is unusual, and operation is nearly always performed in an asymptomatic patient in whom the fistula is closed to prevent future symptoms or complications. The operation chosen is generally interruption of the fistula by direct ligation. Sometimes cardiopulmonary bypass is required. The results are good, with low morbidity (3.6% myocardial infarction) and low mortality (2%) justifying the operation, to be carried out prophylactically even in asymptomatic patients.

Pulmonary atresia or severe stenosis and coronary artery-to-pulmonary artery fistula

Five patients have had the common features of pulmonary atresia or severe stenosis associated with a septal defect and a coronary artery-to-pulmonary artery (CA-PA) fistula. Four had pulmonary valvular atresia, and one had severe pulmonary stenosis. In all five, the CA-PA fistula contributed the principal component of the pulmonary blood flow. Cyanosis, continuous murmur, right ventricular hypertrophy, and decreased or normal pulmonary vascularity were frequent clinical manifestations, but angiocardiography was required to establish the diagnosis. The fistula was a side-to-side communication between the left coronary artery and the main pulmonary artery in each of the five patients. The dilated proximal coronary artery connecting the aortic root with the pulmonary artery gave a unique angiocardiographic appearance distinguishing it from truncus arteriosus or aorticopulmonary window. It is suggested that this unique angiocardiographic appearance be called an "aorticopulmonary tunnel." The surgical repair of this anomaly is closely related to that for severe tetralogy of Fallot and should involve a comparable risk and achieve a comparable result.