Coronary artery fistula: a pulsed Doppler/two-dimensional echocardiographic study

Congenital coronary artery abnormalities

Congenital coronary artery abnormalities are rare and account for approximately 0.1 to 2% of congenital heart defects. They may pose significant risk of mortality or morbidity to the patient. The pediatrician and the pediatric cardiologist should be aware of their subtle but very serious presentations and diagnostic steps to be undertaken to pinpoint the diagnosis. Prevention of serious complications from these abnormalities can be achieved by making the appropriate diagnosis and performing timely surgical intervention. This review will discuss the most common congenital coronary artery abnormalities and their management.

Intraoperative transesophageal echocardiography of coronary artery fistulas

Coronary artery fistula is a rare abnormality but one with substantial surgical importance, as operation abolishes the fistulous shunt volume, progressive coronary dilatation, and potential coronary steal. Prior reports emphasize the utility of direct inspection on cardiopulmonary bypass, with visualization of drainage of blood or cardioplegia from the fistulous connection, to define the drainage site. We report 3 patients in whom intraoperative transesophageal echocardiography was used for precise localization of the fistulous drainage site, selective demonstration of vessels feeding the fistulas, and documentation of abolition of fistulous flow, all without need for cardiopulmonary bypass. In addition, the technique provides for continuous monitoring of ventricular function, providing the opportunity to detect inadvertent ischemic effects of ligation. This approach appears to have considerable utility.

Doppler and 2D echocardiographic diagnosis of congenital coronary artery fistulae to the right cardiac chambers: report of 3 cases

We present three cases of coronary artery fistulae to the right cardiac chambers. The first was a 2-day-old neonate in congestive heart failure: 2D and Doppler echocardiography revealed a dilated proximal left coronary artery and a fistulous connection to the right atrium. The other two patients, respectively 4 and 3 years old, were asymptomatic and presented with a continuous heart murmur: a left coronary artery fistula into the right ventricle was detected by ultrasound in one, and a dilated proximal right coronary artery in the other. The diagnosis was confirmed in all three patients. The first patient was operated upon at 18 months of age; the second patient is awaiting surgery, and in the third patient the fistula was ligated at the age of 3 years. The possibility of ultrasound diagnosis without invasive procedures is suggested.

Transesophageal echocardiography in adults with a continuous precordial murmur

In order to assess the ability of echocardiography in the detection of intracardiac and extracardiac shunts, we studied 11 patients (aged 22-64 yr) with a continuous precordial murmur using transthoracic and transesophageal echocardiography, and correlated the results with the subsequent angiographic and surgical findings. We found that only in 5 of 6 patients with a patent arterial duct could the continuous flow pattern be detected in pulmonary artery using transthoracic echocardiography, whereas it could be readily and accurately identified by transesophageal echocardiography in all patients. The diameters of the patent arterial duct were also measured and found to be in good correlation with subsequent surgical findings (r = 0.98, p less than 0.05). In 2 patients with a ruptured aneurysm of sinus of Valsalva which originated from the right coronary sinus and perforated into the right ventricle, transesophageal echocardiography gave a better image than transthoracic echocardiography. In 2 patients with coronary artery fistula, the origin and site of drainage of the coronary artery could be imaged using transesophageal echocardiography, but the course of coronary artery fistula was more easily detected by transthoracic echocardiography. In one patient with aortopulmonary window, the defect between ascending aorta and main pulmonary artery could readily be imaged by transesophageal echocardiography. We therefore recommend transesophageal echocardiography when evaluating patients with precordial continuous murmur in whom intracardiac and extracardiac shunts or defects are suspected.

Successful percutaneous closure of a complex coronary-to-pulmonary artery fistula using a detachable balloon: benefits of intra-procedural physiologic and angiographic assessment

A 48-yr-old woman presented with a loud continuous precordial murmur and symptoms of fatigue. Color-flow doppler imaging and nuclear magnetic resonance imaging failed to show the cause of the murmur. Diagnostic catheterization showed a large left anterior descending coronary artery to pulmonary artery fistula with impaired left ventricular wall motion. Two detachable balloons were deployed in the fistula with complete abolition of flow in the main fistula channel. A small parallel channel of the fistula, previously not appreciated due to vessel overlap, remained patent but had trivial flow as assessed by green-dye and oximetric techniques. The patient had immediate resolution of her symptoms and return of normal ventricular wall motion.

Bilateral coronary arteriovenous fistulas

A 14-year-old girl with bilateral coronary arteriovenous fistulas (CAVFs) draining into the right ventricle (RV) is presented. Selective coronary angiography revealed involvement of both right and left coronary arteries in the fistulous formation, but communication into the RV was single.

Doppler color flow imaging in detection and mapping of left coronary artery fistula to right ventricle and atrium

Two patients who had left coronary artery fistulas that drained into the right ventricle (case 1) and right atrium (case 2) were studied with combined two-dimensional echocardiography and Doppler color flow imaging. The origin of the fistulas from the left coronary artery, their course, and drainage sites were readily identified. These cases illustrate the enhanced identification of left coronary artery fistulas and the drainage sites with the addition of Doppler color flow imaging to two-dimensional echocardiography.

Diagnosis of coronary artery fistula by two-dimensional echocardiography, pulsed Doppler ultrasound and color flow imaging

Ten consecutive patients with a coronary artery fistula, aged 1 day to 4 years, were studied by two-dimensional echocardiography, pulsed Doppler ultrasound and color flow imaging. All patients underwent cardiac catheterization, and seven patients had surgical closure of the fistula. The origin, course and site of drainage of the coronary artery fistula were correctly identified prospectively by echocardiographic examination in all patients. Color flow imaging was particularly helpful in visualizing the site of drainage of the fistula. Diameters of the right and left coronary arteries at their origin and of the aortic root were measured from two-dimensional echocardiographic frames and compared with measurements obtained in normal children. The ratio of coronary artery diameter to aortic root diameter in normal children was 0.14 +/- 0.03 (mean +/- SD) for the right coronary artery and 0.17 +/- 0.03 for the left coronary artery. These normal ratios were greatly exceeded for coronary arteries feeding the fistula, and ranged from 0.68 to 0.84 for the right coronary artery and from 0.34 to 0.52 for the left coronary artery. All anatomic information needed for surgical treatment of coronary artery fistula was consistently obtained by echocardiography with color flow imaging. The fistula was closed from within the heart in five patients and by ligation from the epicardial surface in two patients. In these latter patients, intraoperative color flow imaging at the time of ligation proved to be extremely valuable in achieving complete closure.

Noninvasive diagnosis of coronary artery fistula by Doppler color flow mapping

Sixteen patients with coronary artery fistula proved by coronary angiography or surgery were studied using two-dimensional echocardiography and Doppler color flow mapping. The coronary artery fistula drained into the right atrium in 4 patients, the right ventricle in 2 and the pulmonary artery in 10. The dilated coronary artery was visualized in 7 of the 16 patients with a fistula, as compared with none of the 40 control subjects. These 7 patients included 5 of 6 patients with a fistula draining into the right atrium or right ventricle and only 2 of 10 patients with a fistula draining into the pulmonary artery. Abnormal flow signals in the dilated coronary artery were visualized with Doppler color flow mapping in five of these seven patients. Color flow imaging visualized abnormal flow signals with mosaic appearance in the pulmonary artery in eight patients, the right atrium in four and the right ventricle in two. The chamber in which abnormal signals were detected corresponded with the entry site of the fistula by angiography. Intraoperative imaging during surgical repair was needed in two cases to confirm ligation of all arteries feeding into the fistula network. In conclusion, Doppler color flow imaging is diagnostically useful to visualize shunt flows originating from the opening or exit of a coronary artery fistula. Furthermore, intraoperative use of this technique may provide confirmation of successful surgical ligation of the fistula.

Evaluation of coronary artery anatomy in patients with tetralogy of Fallot by two-dimensional echocardiography

A major coronary artery crossing the right ventricular outflow tract in patients with tetralogy of Fallot interferes with a transannular patch, and preoperative detection of this artery is important. We evaluated the ability of two-dimensional echocardiography to define noninvasively the coronary artery anatomy in 37 consecutive patients (age range, 1 day to 18 years; mean age, 40.9 months). The origin and distribution of the right anterior descending and circumflex coronary arteries, as well as any anteriorly coursing vessel, were examined from parasternal views. Complete studies were obtained in 29 (78%) of the 37 patients. Coronary artery anatomy was determined to be normal by echocardiography in 20 (69%) of the 29 patients. An anterior vessel across the right ventricular outflow tract was detected in the remaining nine patients. Six patients had an anterior descending artery from the left main coronary artery (paired anterior descending arteries in three patients, a right anterior descending artery from the left main coronary artery in two patients, and a right coronary-to-pulmonary artery fistula in one patient). Three patients had no anterior descending artery from the left main coronary artery (anterior descending artery from the right main coronary artery in two patients, and anterior descending and circumflex arteries from the right main coronary artery in one patient). Angiography, surgery, or autopsy confirmed the diagnoses in all but the final patient in whom the anterior descending artery arose from the right main coronary artery as observed at surgery, but the circumflex artery was not seen. Accurate evaluation of coronary artery anatomy is possible by echocardiography in the majority of patients with tetralogy of Fallot. Noninvasive identification of a major coronary artery coursing anteriorly can influence the timing of cardiac catheterization and surgery and the need for angiography.

An unusual presentation of right coronary artery fistula

A four year old girl with infective endocarditis had unexplained facial swelling. Cross sectional echocardiography showed that a large right coronary artery fistula to the right atrium was obstructing the distal superior vena cava. The diagnosis was confirmed by cardiac catheterisation and at operation. The child was symptom free one year after operation.

Noninvasive imaging of left coronary arteriovenous fistula

We investigated a patient with coronary arteriovenous fistula (CAVF) by two-dimensional echocardiography (2-DE), cardiac Doppler, cardiac catheterization and nuclear magnetic resonance (NMR). These investigations clearly showed the abnormal vascular structures. NMR is another valuable noninvasive and safe method of confirming the presence of a CAVF.

Two-dimensional and Doppler echocardiographic features of left circumflex coronary artery to right ventricle fistula: case report and literature review

We report the case of a seven-month-old infant with a clinical diagnosis of patent ductus arteriosus whose two-dimensional and Doppler echocardiographic examinations were consistent with a coronary artery fistula. At angiography, a left circumflex coronary artery to right ventricle fistula was diagnosed. Echo-Doppler techniques for the noninvasive diagnosis of this lesion are discussed and the literature is reviewed.