Huge right ventricle-right coronary artery fistula compromising right ventricular function in a patient with pulmonary atresia and intact ventricular septum: a case report

Incidental congenital coronary artery vascular fistulas in adults: Evaluation with adenosine-13N-ammonia PET-CT

AIM

To assess the functionality of congenital coronary artery fistulas (CAFs) using adenosine stress 13N-ammonia positron emission tomography computed tomography (PET-CT).

METHODS

Congenital CAFs were incidentally detected during coronary angiography (CAG) procedures in 11 adult patients (six males and five females) with a mean age of 64.3 years (range 41-81). Patients were collected from three institutes in the Netherlands. The characteristics of the fistulas (origin, pathway and termination), multiplicity of the origins and pathways of the fistulous vessels were assessed by CAG. Five patients underwent adenosine pharmacologic stress 13N-ammonia PET-CT to assess myocardial perfusion and the functional behavior of the fistula.

RESULTS

Eleven patients with 12 CAFs, 10 unilateral and one bilateral, originating from the left anterior descending coronary artery (n = 8), right coronary artery (n = 2) and circumflex (n = 2). All fistulas were of the vascular type, terminating into either the pulmonary artery (n = 11) or coronary sinus (n = 1). The CAG delineated the characteristics of the fistula (origin, pathway and termination). Multiplicity of the origins and pathways of the fistulous vessels were common in most fistulas (8/12, 67% and 9/12, 75%, respectively). Multiplicity was common among the different fistula components (23/36, 64%). Adenosine pharmacologic stress 13N-ammonia PET-CT revealed normal myocardial perfusion and ejection fraction in all but one patient, who showed a reduced ejection fraction.

CONCLUSION

PET-CT may be helpful for assessing the functional status of congenital CAFs in selected patients regarding clinical decision-making. Studies with a larger patient series are warranted.

Bi-directional flow in coronary-to-left ventricular fistula

Coronary artery fistulae are rare congenital anomalies occasionally observed during coronary angiography. We present a case of retrograde coronary opacification during left ventriculography. This is the first reported case of angiographically documented bi-directional flow in these structures. Due to advanced age and personal wishes, the patient was treated medically. The epidemiology, pathophysiology, and therapy for coronary fistulae are briefly discussed.

Successful repair of a huge right coronary artery to a right ventricular fistula: report of a case

Congenital coronary artery fistulas account for only 0.27%-0.4% of all congenital cardiac defects. We report a case of a right coronary artery (RCA) to a right ventricular(RV) fistula found in 14-year-old girl with clinical signs of heart failure. Echocardiography and cardiac catheterization showed the fistula and a dilated RCA with a diameter of 10 mm. Operative intervention was required, so we performed intracardiac closure of the ventricular fistulous opening under cardiopulmonary bypass (CPB). The patient recovered uneventfully. This method of closure spares the involved coronary artery and is associated with a low risk of recurrence or residual fistula.

Biventricular repair for pulmonary atresia with intact ventricular septum associated with sinusoidal communications

Pulmonary atresia with intact ventricular septum (PA-IVS) is very difficult to treat due to the variety of right ventricular hypoplasia and coronary artery anomalies. Biventricular repair is viewed as possible in patients with mild right ventricular hypoplasia but not in those with severe right ventricular hypoplasia or with sinusoidal communication. We report a case of a 17-day-old boy with PA-IVS and severe right ventricular hypoplasia and large sinusoidal communications. We successfully conducted biventricular repair, ligated coronary artery and right ventricular fistulas, and implemented right ventricular outflow tract reconstruction. He now enjoys good health and attends elementary school. Sinusoidal communications are not always a limiting factor in biventricular repair for PA-IVS if the right ventricle can be decompressed without inviting ventricular dysfunction by ligating fistulas.