Congenital aneurysm of the right coronary artery with fistulous connection to the right atrium

Cardiac-CT with the newest CT scanners: An incoming screening tool for competitive athletes?

Competitive athletes of all skill levels are at risk of sudden cardiac death (SCD) due to certain heart conditions. Prior to engagement in high-intensity athletics, it is necessary to screen for these conditions in order to prevent sudden cardiac death. Cardiac-CT angiography (CCTA) is a reliable tool to rule out the leading causes of SCD by providing an exceptional overview of vascular and cardiac morphology. This allows CCTA to be a powerful resource in identifying cardiac anomalies in selected patients (i.e. unclear symptoms or findings at ECG or echocardiography) as well as to exclude significant coronary artery disease (CAD). With the advancement of technology over the last few years, the latest generations of computed tomography (CT) scanners provide better image quality at lower radiation exposures. With the amount of radiation exposure per scan now reaching the sub-millisievert range, the number of CT examinations it is supposed to increase greatly, also in the athlete's population. It is thus necessary for radiologists to have a clear understanding of how to make and interpret a CCTA examination so that these studies may be performed in a responsible and radiation conscious manner especially when used in the younger populations. Our work aims to illustrate the main radiological findings of CCTAs and highlight their clinical impact with some case studies. We also briefly describe critical features of state-of-the-art CT scanners that optimize different acquisitions to obtain the best quality at the lowest possible dose.

Surgical outcome of coronary artery fistulas repair in children

Coronary artery fistula (CAF) is a rare congenital anomaly that can be complicated by endocarditis, myocardial infarction, or coronary aneurysms. This article reviews the clinical characteristics and surgical outcome of 10 patients with CAF in Rajae Heart Center. From 1990 to 2000, 10 patients (age, 6 months to 15 years; mean age, 8.5 years) were diagnosed with CAF by echocardiography and cardiac catheterization. Six were female and 4 were male. All patients with isolated CAF (9) were asymptomatic. One patient with associated anomaly (mitral valve prolapse with severe mitral regurgitation) had dyspnea on exertion and palpitation. Five fistulas originated from the right coronary artery-three from the left and two from the left circumflex. Drainage was to the right ventricle (7), right atrium (2), and pulmonary artery (1). The ratio of pulmonary to systemic flow ranged between 1 and 1.6. All patients had surgical ligation. In the symptomatic patient, in addition to ligation, mitral valve replacement was performed. There was no operative or late death. Follow-up evaluation (range, 1-6 years; mean, 4.2 years) showed no evidence of recurrent or residual CAF. Surgical management of CAF is a safe and effective treatment resulting in 100% survival and clousure rate.

Multiple coronary artery fistulas with a huge right coronary artery showing exacerbation during 16 years of follow-up

A 38-year-old Japanese woman underwent cardiac evaluation to assess an arrhythmia detected after the delivery of her fourth baby. At the age of 22 years, she had undergone cardiac evaluation, including catheter examination, because of a heart murmur. Coronary angiography showed a huge right coronary artery (RCA) draining to the right atrium and a normal left coronary artery. Because the left to right shunt ratio was trivial and the patient was asymptomatic, conservative observation was undertaken. On the current admission to hospital, there was a grade III continuous murmur at the second left sternal border. The patient underwent right and left cardiac catheter examination in March 2000. Selective coronary angiography demonstrated an enlarged lumen of the RCA, an enlarged aneurysmal cavity in the terminal portion of the RCA, and the postero-descending artery being filled by collateral circulation from the left coronary artery. Moreover, 2 new fistulas had appeared from the left coronary system. An oxygen saturation study showed that the pulmonary to somatic flow ratio (Qp/Qs) was 2.2. The patient underwent surgical treatment in July 2000 and on coronary angiography 1 month later, there was no abnormal shunt flow from either coronary artery into the aneurysmal cavity, although the RCA was still enlarged.

Giant coronary artery aneurysm arising from sinus node artery

A giant coronary aneurysm arising from the sinus node artery is reported. Diagnosis of this lesion by computed tomography and angiography is illustrated. The operative management is described. "Off-pump" aneurysmectomy was successfully performed. The role of occlusion test of the aneurysm inflow tract is emphasized.

Intraoperative localisation and management of coronary artery fistula using transesophageal echocardiography

Coronary artery fistula is a rare congenital malformation that can be complicated by intracardiac shunts, endocarditis, myocardial infarction, coronary aneurysm and sudden death. Clinical symptomatology depends upon the underlying anatomy and the size of the fistulous connection between the left or right side of the heart. We report the successful management of a giant right coronary artery with fistulization into the right atrium. Intraoperative transesophageal echocardiography with colour flow Doppler was used for precise location of the fistulous communication, selective demonstration of vessels feeding the fistula and documentation of abolition of fistulous flow all without the need for cardiopulmonary bypass. Furthermore the effect of shunt occlusion on regional wall motion was documented which facilitated the successful ligation of the fistula.

Prognostic significance of clinically silent coronary artery fistulas

Symptomatic coronary artery fistulas (CAF) are associated with significant morbidity and mortality. With the advent of high-resolution 2-dimensional and color Doppler echocardiography, the detection rate of clinically silent CAF has increased, but their clinical significance and outcome have not been defined. The clinical, echocardiographic, electrocardiographic, and angiographic findings and documented follow-up of 31 patients with an echocardiographic finding of a clinically silent coronary artery fistula from 1986 to 1997 were analyzed. Mean age at diagnosis was 7.2+/-8.4 years. Indications for echocardiography were murmur (n = 23), congenital heart disease (n = 2), cardiomegaly (n = 2), chest pain (n = 1), stridor (n = 1), syncope (n = 1), and chest trauma (n = 1). CAF were detected with color Doppler flow mapping in all patients. The origin of the fistula was from the left coronary artery system (n = 27), right coronary artery system (n = 3), and bilateral (n = 1). The exit sites were the pulmonary artery (n = 18), right ventricle (n = 8), right atrium (n = 2), and left ventricle (n = 3). Global and regional left ventricular function were normal in all patients at presentation and follow-up. Spontaneous closure of the fistula was documented in 7 patients (23%) at mean follow-up of 2.6+/-2.0 years. In 23 patients the fistula persisted without intervention. All patients remained asymptomatic, without adverse clinical events or evidence of ischemia at a mean age at follow-up of 9.3+/-9.1 years (range 4 months to 42.0). Based on this experience, there is no evidence that clinically silent CAF diagnosed incidentally by color Doppler echocardiography are associated with adverse clinical outcome in childhood and adolescence. Conservative management with continued follow-up of these patients appears to be appropriate.

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.

Congenital coronary artery fistula suggesting a "steal phenomenon" in a neonate

The case of a neonate reported herein demonstrates a congenital fistula between the left circumflex coronary artery and the right ventricle. Intraoperative stress to the patient's heart suggested a coronary "steal phenomenon."

Aortoatrial fistulae diagnosed by transthoracic and transesophageal echocardiography: advantages of the transesophageal approach

Aortoatrial fistulae are uncommon, providing a difficult diagnostic challenge both in the clinical diagnosis and in the choice of an imaging modality that fully delineates the abnormal anatomy and flow patterns. This report describes four cases of aortoatrial fistula resulting from three different underlying causes. The fistula communicated with the right atrium in three cases and the left atrium in one. We also describe the diagnostic information obtained during both transthoracic and transesophageal echocardiography and stress that full detail of the abnormal anatomy and shunting could be obtained only with the transesophageal approach, with its improved image quality of the aortic root. No extra information, other than the coronary anatomy, was obtained during aortography in the two patients who underwent cardiac catheterization. Transesophageal echocardiography should, therefore, be the investigation of choice in patients in whom there is a suspicion of aortoatrial shunting after clinical examination and routine transthoracic studies, and it may avoid the need for invasive investigation in these potentially hemodynamically unstable patients.

A five-chambered heart: rare coronary artery anomaly with fistula draining into a separate interventricular cavity

The combination of color flow Doppler imaging, contrast echocardiography, magnetic resonance imaging, and coronary arteriography documented the presence of a right coronary artery fistula that opened into a separate cavity in the anterior part of the interventricular septum in a 32-year-old man. Although a traumatic origin could not be excluded, the abnormality was most likely a congenital anomaly. Because there were no significant symptoms and no signs of hemodynamic burden on the heart, a conservative management was decided and no complications occurred during 3 years of follow-up. So far the literature includes only one similar case described by autopsy findings.

Coronary arteriovenous fistula presenting as congestive heart failure

Coronary arteriovenous fistulae are rare, but can be of hemodynamic significance. We report a circumflex-coronary sinus fistula in an elderly man which was associated with a loud continuous murmur and congestive heart failure. Noninvasive evaluation, including transesophageal echocardiography and magnetic resonance imaging, suggested the diagnosis. Angiographic diagnosis of concomitant atherosclerotic coronary disease may be difficult, and can require postoperative study.