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Chevenon M, Reynolds H, Lin J, Sabati A, Nowlen T. Single Center Retrospective Evaluation of Coronary Artery Fistula Outcomes. Pediatr Cardiol 2024:10.1007/s00246-024-03600-y. [PMID: 39048635 DOI: 10.1007/s00246-024-03600-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2024] [Accepted: 07/16/2024] [Indexed: 07/27/2024]
Abstract
There is a paucity of literature describing long-term outcomes of patients with coronary artery fistula with most manuscripts focusing on those requiring interventions. We describe single-center outcomes of coronary artery fistulas including those not requiring intervention. We performed a retrospective review of the electronic medical record and identified all patients with a diagnosis of coronary artery fistula over the last 10 years. 158 patients were identified with a coronary artery fistula. The mean age at diagnosis was 5.8 years (SD ± 5.9). There was a male (55%, n = 87) predominance. Concomitant congenital heart lesion was present in 49% (n = 77) and a genetic anomaly was found in 18% (n = 29). No ischemic changes on electrocardiogram or ECG-stress test were observed. The mean follow-up was 5.0 (SD ± 3.8) years. Most patients (94%, n = 149) did not undergo an intervention. Of those 63% (n = 94) had at least one follow-up echocardiogram. There was spontaneous coronary artery fistula closure in 44% (n = 41), 8% (n = 8) decreased in size, and 48% (n = 45) were unchanged. No patient had enlargement of the coronary artery fistula over time. Additionally, tiny and small coronary artery fistulas showed no significant clinical changes in coronary artery dimensions, left ventricle dimensions and function over time. Seven patients required intervention; two patients underwent surgical ligation and five underwent catheter-based intervention. Most patients with coronary artery fistula in our cohort did not require intervention and over half either closed spontaneously or decreased in size with routine follow-up.
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Affiliation(s)
- M Chevenon
- Pediatric Cardiology, Phoenix Children's, Phoenix, AZ, USA.
| | - H Reynolds
- Pediatric Cardiology, Phoenix Children's, Phoenix, AZ, USA
| | - J Lin
- Pediatric Cardiology, Phoenix Children's, Phoenix, AZ, USA
| | - A Sabati
- Pediatric Cardiology, Phoenix Children's, Phoenix, AZ, USA
- Department of Child Health, Pediatric Cardiology, University of Arizona, Phoenix, AZ, USA
| | - T Nowlen
- Pediatric Cardiology, Phoenix Children's, Phoenix, AZ, USA
- Department of Child Health, Pediatric Cardiology, University of Arizona, Phoenix, AZ, USA
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Wu S, Fares M, Zellers TM, Jyothinagaram M, Reddy SRV. Diagnosis and Management of Congenital Coronary Artery Fistulas in Infants and Children. Curr Cardiol Rep 2023; 25:1921-1932. [PMID: 38051412 DOI: 10.1007/s11886-023-02007-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/26/2023] [Indexed: 12/07/2023]
Abstract
PURPOSE OF REVIEW Coronary artery fistulas (CAFs) are rare coronary anomalies that most often occur as congenital malformations in children. Although most children with CAFs are asymptomatic at the time of diagnosis, some present with symptoms of congestive heart failure in the setting of large left-to-right shunts. Others may develop additional complications including coronary artery ectasia and coronary thrombosis. Surgical and transcatheter closure techniques have been previously described. This review presents the classifications of CAFs in children and the short and long-term outcomes of CAF closure in children in the reported literature. We also summarize previously-reported angiographic findings and post-treatment remodeling characteristics in pediatric patients. RECENT FINDINGS With advancements in cross-sectional imaging technologies, anatomic delineation of CAFs via these modalities has become crucial in procedural planning. Recent reports of surgical and transcatheter closure of CAFs in children have reported good procedural success and low rates of short-term morbidity and mortality. Distal-type CAFs have elevated risk for long-term sequelae post-closure compared to proximal-type CAFs. A recent report of a multi-institutional cohort also describes post-closure remodeling classifications which may predict long-term outcomes in these patients as well as guide individualized anticoagulation management. Invasive closure of significant CAFs via surgical or transcatheter techniques is feasible and safe in most children with good short and intermediate-term outcomes. However, close clinical and imaging follow-up is required to monitor for late complications even after successful closure. Antiplatelet and anticoagulation regimens remain important aspects of post-closure management, but the necessary intensity and duration of such therapy remains unknown.
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Affiliation(s)
- Stephan Wu
- Division of Cardiology, Department of Pediatrics, University of Texas Southwestern Medical Center, Children's Health System of Texas, Childrens Medical Center, 1935 Medical District Drive, Dallas, TX, 75235, USA.
| | - Munes Fares
- Division of Cardiology, Department of Pediatrics, University of Texas Southwestern Medical Center, Children's Health System of Texas, Childrens Medical Center, 1935 Medical District Drive, Dallas, TX, 75235, USA
| | - Thomas M Zellers
- Division of Cardiology, Department of Pediatrics, University of Texas Southwestern Medical Center, Children's Health System of Texas, Childrens Medical Center, 1935 Medical District Drive, Dallas, TX, 75235, USA
| | - Maanya Jyothinagaram
- Division of Cardiology, Department of Pediatrics, University of Texas Southwestern Medical Center, Children's Health System of Texas, Childrens Medical Center, 1935 Medical District Drive, Dallas, TX, 75235, USA
| | - Surendranath R Veeram Reddy
- Division of Cardiology, Department of Pediatrics, University of Texas Southwestern Medical Center, Children's Health System of Texas, Childrens Medical Center, 1935 Medical District Drive, Dallas, TX, 75235, USA
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Amoozgar H, Edraki MR, Naghshzan A, Mehdizadegan N, Mohammadi H, Ajami G, Amirghofran AA. Midterm follow up of transcatheter closure of coronary artery fistula with Nit-Occlud® patent ductus arteriosus coil. BMC Cardiovasc Disord 2021; 21:192. [PMID: 33879042 PMCID: PMC8056487 DOI: 10.1186/s12872-021-01999-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Accepted: 04/09/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Coronary artery fistula (CAF) is a rare congenital anomaly with a challenging scenario in children. This study reports our experience in transcatheter closure of CAF with Nit-Occlude PDA coil and midterm clinical and imaging follow-up. METHODS Twelve children with congenital CAF between 2009 and 2019, mean age 2.05 ± 2.05 years (4 days to 7.2 years), mean weight 8.8 ± 4.83 (2.8-17 kg), who underwent transcatheter closure with PFM coil at the Namazi hospital, Shiraz, Iran, were reported. Echocardiography and electrocardiogram were done before and after the procedure (early, 3, and 6 months after), and Multi-slice computerized tomography or conventional coronary angiography was performed at least one year after closure. RESULTS In a median follow-up of 5.5 years (range 13 months to 8 years), retrogradely closed fistula had no residual, and the fistula tract was wholly occluded, but in most anterogradely closed fistula, had a small residual, which made the fistula tract open and need additional coil closure. CONCLUSIONS Transcatheter closure of CAF with PFM coil is feasible and effective with low mortality and morbidity, although antegrade closure with this device may be accompanied by residual shunt and need for multiple coil insertion.
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Affiliation(s)
- Hamid Amoozgar
- The Neonatal Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.,Department of Pediatrics, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mohammad Reza Edraki
- The Cardiovascular Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Amir Naghshzan
- The Neonatal Research Center, Shiraz University of Medical Sciences, Shiraz, Iran. .,Department of Pediatrics, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran. .,Cardiovascular and Neonatology Research Center, Namazi Hospital, Shiraz University of Medical Sciences, Shiraz, Iran.
| | - Nima Mehdizadegan
- The Cardiovascular Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.,Department of Pediatrics, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Hamid Mohammadi
- The Neonatal Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Gholamhossein Ajami
- The Neonatal Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
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Long-Term Follow-Up of Pediatric Patients After Congenital Coronary Artery Fistula Closure. Pediatr Cardiol 2020; 41:1346-1353. [PMID: 32474739 DOI: 10.1007/s00246-020-02379-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Accepted: 05/22/2020] [Indexed: 10/24/2022]
Abstract
The surgical closure of congenital coronary artery fistulas (CAF) is associated with excellent immediate outcomes. Few studies have investigated the long-term prognosis in patients who have undergone surgery for the closure of CAF or differentiated among types of CAF or types of surgical procedures. In this study, we performed clinical examinations and computed tomography angiography (CTA) to characterize outcomes after CAF closure in pediatric patients. The medical records of 79 pediatric patients who underwent surgical closure of CAF were retrospectively reviewed. The median age of the patients included in the study at the time of surgery was 3.4 years (range 0.2 to 15.3 years). The patients had been followed up for 11 years (range 1 to 17 years) with electrocardiography, echocardiography, and coronary CTA. There were 67 medium-to-large CAF and 12 small CAF. Twenty-six (32.9%) CAF arose from the branch coronary artery (proximal type); the others arose from the parent coronary artery (distal type). The surgical procedure included endocardial closure in 16 cases, epicardial distal ligation in 51 cases, epicardial proximal and distal ligation in 12 cases. There was no instance of perioperative death among the cases included in the study. Twenty-eight patients were treated with antiplatelet medication postoperatively. No patient required re-operation during the follow-up period. Coronary thrombi were detected in 27 patients (34.2%). There was no instance of myocardial ischemia related to thrombosis. Among the patients with thrombosis, 26 had medium-to-large CAF (96.3%), and 23 had distal-type CAF (85.2%). Average age at surgery was higher among the patients with thrombosis than among the patients without thrombosis (7.4 years vs. 3.3 years, t = 5.509, P = 0.000). Among the patients with distal-type CAF, thrombosis was more common among the patients treated with ligation than treated with endocardial closure (41.5% vs. 16.7%, χ2 = 3.742, P = 0.043). There was no difference in risk for thrombosis between the patients who did vs. did not receive antiplatelet therapy (P = 0.436). The most common complication after CAF closure was thrombosis. Increased risk for thrombosis was associated with large fistulae, distal-type CAF, and older age at presentation. Antiplatelet treatment did not appear to decrease the risk of thrombosis. Among patients with distal-type CAF, risk for thrombosis was lower among patients treated with endocardial closure, compared with patients treated with epicardial ligation.
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VanderWielen BA, Dong YJ, Borden SB. Perioperative anesthetic management of an 18-month-old pediatric patient with a congenital coronary fistula between the left circumflex coronary artery and coronary sinus: Report of a rare case. Ann Card Anaesth 2020; 23:347-350. [PMID: 32687097 PMCID: PMC7559957 DOI: 10.4103/aca.aca_127_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
We present a case of an 18-month-old, 8.69 kg, female, who presented with a coronary fistula between the left circumflex coronary artery and coronary sinus (CS) for remote computed tomography (CT) imaging and transcatheter closure. This is the fifth published case report to describe this congenital anomaly and the first to discuss general anesthesia (GA) and the hemodynamic management considerations for the anesthesiologist.
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Affiliation(s)
- Beth A VanderWielen
- Department of Anesthesiology, Gundersen Health System, La Crosse, Madison, WI, USA
| | - Yuanxu J Dong
- Department of Anesthesiology, American Family Children's Hospital, Madison, WI, USA
| | - Shelly B Borden
- Department of Anesthesiology, University of Wisconsin Hospital and Clinics, Madison, WI, USA
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Christmann M, Hoop R, Dave H, Quandt D, Knirsch W, Kretschmar O. Closure of coronary artery fistula in childhood: treatment techniques and long-term follow-up. Clin Res Cardiol 2016; 106:211-218. [PMID: 27730300 DOI: 10.1007/s00392-016-1041-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Accepted: 10/05/2016] [Indexed: 01/24/2023]
Abstract
INTRODUCTION Coronary artery fistula (CAF) is a rare congenital anomalous connection between the coronary arteries (CA) and a cardiac chamber or great vessel. Treatment options of symptomatic CAF consist of transcatheter or surgical closure. METHODS Retrospective analysis of all patients with CAF diagnosed between 1993 and 2014 concerning treatment approaches and follow-up after closure. RESULTS In a cohort of more than 25000 patients, 194 (<0.01 %) were diagnosed to have CAF. Median age at diagnosis was 6 months (0 day-18 years). Treatment was indicated in ten patients (5.2 %). Six patients (60 %) were treated by catheter interventional approach using Coils (three patients), Amplatzer Vascular Plugs (two patients) and Amplatzer Duct Occluder (one patient). One of these patients showed a significant residual shunt through the fistula 5 days after interventional closure, necessitating surgical removal of the device and closure of CAF. At a median follow-up of 7 (range 2-12) years, the remaining five patients showed successfully closed CAF without causing thrombosis of the CA. Control angiography in three patients showed persistent dilated CA. Surgical closure of CAF was performed in four (40 %) patients; in two as an isolated procedure and in the remaining two as a part of another congenital cardiac corrective procedure. CONCLUSIONS CAF in paediatric cardiology patients is a very rare finding. Intervention in childhood is rarely needed; nevertheless, it is known that small fistulas may become relevant in adulthood. Transcatheter closure techniques are effective and are considered the treatment of choice, especially in isolated CAF.
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Affiliation(s)
- Martin Christmann
- Paediatric Cardiology, University Children's Hospital, Steinwiesstrasse 75, 8032, Zurich, Switzerland.
| | - Ricarda Hoop
- Paediatric Cardiology, University Children's Hospital, Steinwiesstrasse 75, 8032, Zurich, Switzerland
- Paediatric Cardiology, Cantonal Hospital Graubunden, Chur, Switzerland
| | - Hitendu Dave
- Division of Congenital Cardiovascular Surgery, University Children's Hospital, Zurich, Switzerland
| | - Daniel Quandt
- Paediatric Cardiology, University Children's Hospital, Steinwiesstrasse 75, 8032, Zurich, Switzerland
| | - Walter Knirsch
- Paediatric Cardiology, University Children's Hospital, Steinwiesstrasse 75, 8032, Zurich, Switzerland
| | - Oliver Kretschmar
- Paediatric Cardiology, University Children's Hospital, Steinwiesstrasse 75, 8032, Zurich, Switzerland
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Anagnostopoulos PV. A large international single-center case-series of coronary artery fistulas in children: When high clinical research standards adopted globally create exciting opportunities for the future. J Thorac Cardiovasc Surg 2016; 152:1131-2. [PMID: 27342732 DOI: 10.1016/j.jtcvs.2016.05.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Accepted: 05/26/2016] [Indexed: 10/21/2022]
Affiliation(s)
- Petros V Anagnostopoulos
- Division of Pediatric Cardiothoracic Surgery, American Family Children's Hospital, University of Wisconsin Hospital and Clinics, Madison, Wis.
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Zhang W, Hu R, Zhang L, Zhu H, Zhang H. Outcomes of surgical repair of pediatric coronary artery fistulas. J Thorac Cardiovasc Surg 2016; 152:1123-1130.e1. [PMID: 27245418 DOI: 10.1016/j.jtcvs.2016.04.093] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Revised: 03/30/2016] [Accepted: 04/30/2016] [Indexed: 12/25/2022]
Abstract
OBJECTIVE Isolated congenital coronary artery fistula is a rare condition, and the surgical experience for treating this condition is limited. METHODS This was a retrospective review of 47 patients who underwent surgical repair of isolated congenital coronary artery fistula from January 2001 to March 2015. RESULTS All but 1 patient presented with no symptoms. The median age at operation was 3.9 years (range, 0.4-15.2 years), and the median weight was 15.2 kg (range, 6.3-77.0 kg). Right coronary artery to right ventricle fistula was the most common pattern, which was present in 16 patients. Epicardial ligation without cardiopulmonary bypass was used to treat 4 patients, whereas cardiopulmonary bypass was used in the remaining 43 patients. Surgical techniques included transcoronary closure in 20 patients, transcameral or transpulmonary closure in 20 patients, a combination of both transcameral and transcoronary closure in 2 patients, and a conversion from transcameral closure to epicardial ligation in 1 patient. There were no deaths during our study period. Injury to the mitral valve occurred in 1 patient. Residual shunt was observed in 8 patients, 2 of which closed spontaneously during the follow-up. Extracardiac repair was associated with a higher risk of recanalization (P = .004). Freedom from recanalization was 89.4%, 85.1%, 83.0%, and 83.0% at discharge, 6 months, 1 year, and 5 years postsurgery, respectively. Two patients required transcatheter closure for residual shunts. CONCLUSIONS Surgical repair of isolated congenital coronary artery fistula in pediatric patients can be performed with low mortality and morbidity. Careful evaluation after surgery is necessary to monitor the occurrence of residual shunt.
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Affiliation(s)
- Wen Zhang
- Department of Cardiothoracic Surgery, Shanghai Children's Medical Center, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Renjie Hu
- Department of Cardiothoracic Surgery, Shanghai Children's Medical Center, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Lei Zhang
- Department of Cardiothoracic Surgery, Shanghai Children's Medical Center, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Hongbin Zhu
- Department of Cardiothoracic Surgery, Shanghai Children's Medical Center, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Haibo Zhang
- Department of Cardiothoracic Surgery, Shanghai Children's Medical Center, Shanghai Jiaotong University School of Medicine, Shanghai, China.
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