Surgical treatment of the coronary artery to pulmonary artery fistulas in adults

Diverse Transcatheter Closure Strategies in Coronary Artery Fistulas A State-of-the-Art Approach

Coronary artery fistulas (CAFs) are accounted as the most congenital coronary anomalies. As their natural course is progressive dilatation of the feeder arteries and the fistula tract, so, catastrophic complications are frequently illustrated by aging. Even in those with asymptomatic small fistulas, close follow-up is mandatory to prevent subsequent sequelas. In patients with medium or large-sized fistulas, irrespective of symptoms, closure (either by surgical ligation or transcatheter closure) is recommended. In the current era of advances in the equipment and devices and also innovations in percutaneous closure techniques and preprocedural imaging, TCC is now regarded as the preferred strategy for CAF closure except in some high-risk cases. So, by appropriate case selection modalities, pre-procedural planning, and determining the closure techniques, recent small case-series studies have been reported good final angiographic and clinical results by TCC. In this article, we have introduced several transcatheter closure techniques by details; also, we have recommended more multi-center trials with long-term clinical follow-up to address the best treatment options in these patients.

Coronary-to-Pulmonary Artery Fistula in Adults: Natural History and Management Strategies

OBJECTIVE

To evaluate the natural course of coronary-to-pulmonary artery fistula (CPAF) detected on coronary computed tomography angiography (CCTA) and to propose potential treatment strategies.

MATERIALS AND METHODS

In this retrospective multicenter study, we assessed the CCTA reports of 188 CPAF patients evaluated between March 2009 and June 2016. Fifty-seven patients were excluded because their follow-up (FU) periods were less than 2 years. Information regarding demographic characteristics, past history, treatment method, and the occurrence of major adverse cardiac events (MACE) during the FU period was collected. We analyzed the morphologic features of CPAF and the various factors associated with surgical treatment. Patients who had undergone FU CCTA after being diagnosed with CPAF were assessed for the presence of morphological changes on FU imaging.

RESULTS

The median age of the study population was 63.0 years (range, 57.0-72.0 years), and the median FU period was 5.72 years (range, 4.08-6.96 years). The most common origin of the CPAF was both coronary arteries in 76 (58.0%) cases. An aneurysm or aneurysms was/were present in 41 (31.3%) cases. Fifty-four (41.2%) fistulas were less than 2 mm in size. Eight patients underwent surgery, and 123 (93.9%) patients received optimal medical treatment (OMT). The fistula size was significantly different between the two treatment groups (p = 0.013) and was the only factor associated with surgical treatment (odds ratio = 1.14, p = 0.021). Only one patient in the OMT group reported MACE during the FU period due to preexisting coronary artery disease. Twenty-nine patients (22.1%) underwent FU CCTA after CPAF diagnosis, with a median FU period of 3.81 years. None of the patients in the OMT group demonstrated morphological changes in the CPAF on FU imaging.

CONCLUSION

Most CPAFs identified on CCTA have a favorable prognosis. Observation with OMT is usually an appropriate strategy. Fistula size is a possible determinant for surgical treatment.

Case Report: Surgical Treatment of High-Flow Coronary Fistulas for the Pulmonary Artery

Coronary fistulas are rare anomalies that can affect approximately 1% of the population, presenting few specific symptoms, and are often found occasionally in coronary angiography. Here we describe the case of a 61-year-old patient with complaints of precordialgia and dyspnea since adolescence, with late diagnosis of coronary fistulas with drainage to the pulmonary artery, and with unsuccessful percutaneous treatment.

Therefore, she underwent open surgery for the correction of the already known fistulas, in addition to the hemangioma involving such vessels, which made the understanding and resolution of this case more complex.

Coronary-to-pulmonary artery fistula in adults: Evaluation with thallium-201 myocardial perfusion SPECT

Objectives

With the increasing use of multi-detector CT, the number of detected cases with coronary-to-pulmonary artery fistula (CPAF) has increased. Several previous studies reported severe cases of angina, but no appropriate tests to evaluate myocardial perfusion for patients with CPAF have been established. We evaluated the hemodynamic characteristics of CPAF using thallium-201 (Tl-201) single photon emission computed tomography (SPECT).

Materials and methods

Tl-201 SPECT was performed in 17 patients with CPAF, but without evidence of coronary artery disease on coronary computed tomography angiography (CCTA) (age, 58.5±13.3 years; 8 men). Quantitative analysis of scintigraphic data was performed. Additionally, perfusion abnormalities were compared with CCTA findings. Medical records were obtained to define clinical data, diagnostic findings, symptoms, management, follow-up data, and major adverse cardiac events (MACE).

Results

Six patients (35.2%) showed perfusion abnormalities on SPECT studies and could be classified as follows: 3 patients, no reversible ischemia (3/17, 17.6%); 1 patient, mild ischemia (1/17, 5.8%); and 2 patients, moderate ischemia (2/17, 11.7%). During the follow-up, ten patients (58.8%) improved under medical management and 5 patients (29.4%) underwent surgical ligation for CPAF with symptomatic improvement in 4 patients. Seven patients performed follow-up myocardial perfusion SPECT, and symptomatic improvement correlated well with scintigraphic perfusion improvement in 6 patients No MACE was observed.

Clinical significance

Tl-201 myocardial perfusion SPECT might be useful for determining the hemodynamic status and for risk stratification in patients with CPAF.

Surgical treatment of coronary arteriovenous fistulas and aortic valve insufficiency

We report a 76-year-old female with Takayasu arteritis who was found to have multiple coronary arteriovenous fistulas (CAVFs), a pulmonary-to-systemic ratio of 2:1, and aortic valve insufficiency. Aortic valve replacement and ligation of multiple CAVFs with cardiopulmonary bypass were performed under cardioplegic arrest, thus minimizing coronary steal.

The primary percutaneous coronary intervention for acute anterior myocardial infarction in a middle-aged male patient with bilateral coronary artery to pulmonary artery fistulas

A 38-year-old man admitted to emergency department with 2 h of typical substernal chest pain, shortness of breath and nausea. The ECG revealed sinus rhythm with a 3 mm ST elevation in precordial leads V1-V6. The coronary angiography revealed acute total occlusion in left anterior descending artery (LAD) with normal circumflex and right coronary artery (RCA) along with bilateral fistulas arising from the proximal LAD and ostial RCA draining into the main pulmonary artery. Therefore, primary percutaneous coronary intervention and bare metal stent implantation was performed to culprit LAD lesion. The electrocardiographically gated 64-slice multidetector-row CT showed two large, tortuous abnormal vessels which arose from the both ostial part of the RCA and LAD draining into the main pulmonary artery. We report an unusual case of bilateral coronary artery to pulmonary artery fistulas leading to acute anterior myocardial infarction in a middle-aged male patient.

Coronary artery fistula

Although coronary arterial fistula is rare, it is one of the most common among the coronary artery anomalies. Coronary arterial fistula most commonly affects the right side of the heart. It may occur isolated or along with congenital heart diseases. Angiography remains the best investigation for diagnosing the disease. Unless very large and hemodynamically significant, it is usually asymptomatic in younger patients. With increasing age, symptoms begin to appear, and the incidence of complication rises. Treatment by transcatheter or surgical closure gives the best results, provided this is performed early in the course of the disease. This review was prepared by searching the terms "coronary artery fistula," "coronary cameral fistula," "surgical management of coronary arterial fistula," "MDCT in coronary artery fistula," and "multiple coronary artery fistulae" in Google Scholar, PubMed, and PubMed Central and exploring the related articles shown on the side of page.

Anomalous Coronary to Pulmonary Artery Fistula and Aneurysm in an 86-Year-Old Female

An anomalous coronary artery to pulmonary artery fistula with concomitant aneurysmal dilation is quite rare, especially in the elderly. We present a case report of an 86-year-old female who presented with congestive heart failure from severe mitral regurgitation and was found to have such a coronary anomaly on preoperative angiography. The natural history, diagnosis, and treatment options are discussed.

Multidetector row computed tomography: imaging congenital coronary artery anomalies in adults

The quality of the imaging of the main coronary arteries and side branches provided by multidetector row computed tomography (MDCT) may have importance when assessing congenital coronary artery anomalies. This review discusses the rationale for using MDCT for this indication and examines the advantages and disadvantages of the technique. Examples of MDCT imaging of congenital coronary artery anomalies are presented. These images provide persuasive evidence to support clinical use of MDCT cardiac imaging in the context of suspected congenital coronary artery anomalies as a first line investigation.

Percutaneous, Catheter-Based Coil Embolization of Coronary Fistula:

A 55-year-old male with angina-like chest pain and positive thallium-scintigraphy was admitted to our hospital. Cardiac catheterization was performed for suspected coronary artery disease. The coronary angiogram showed no significant epicardial stenosis, but a large coronary fistula, connecting the left anterior descending artery with the pulmonary artery. Swan-Ganz catheter measurements, intracoronary Doppler, and quantitative coronary angiography were used to determine cardiac output, coronary blood flow, and coronary-to-pulmonary artery shunt fraction. These measurements showed a hyperdynamic cardiac output of 17 L/min, a coronary blood flow of 140 mL/min in the left anterior descending coronary artery with an estimated shunt fraction of 58% into the pulmonary circulation. Percutaneous, catheter-based coil embolization was performed to occlude the fistula. After embolization of one coil, coronary angiography showed the fistula's stump only. Cardiac output (9 L/min) and coronary blood flow (48 mL/min) were almost normalized. The patient was discharged from the hospital the day after the procedure. After a 6-month follow-up, there were still no complaints, angina-like symptoms or signs of myocardial ischemia in stress tests.

Successful concomitant treatment of a coronary-to-pulmonary artery fistula and a left anterior descending artery stenosis using a single covered stent graft: a case report and literature review

This report describes a case of a 47-year-old man who presented with early post-Q wave myocardial infarction angina and an atherosclerotic left anterior descending stenosis associated to a coronary-to-pulmonary artery fistula. Both coronary stenosis and fistula were successfully treated with a single polytetrafluoroethylene-covered stent graft implantation by intravascular ultrasound-guided procedure.

Myocardial ischemia secondary to a large coronary-pulmonary fistula--a case report

Coronary-pulmonary fistulas are rare. The majority of these fistulas arise from the left anterior descending or the right coronary arteries; the circumflex coronary artery is rarely involved. The majority of patients are asymptomatic, but heart failure, angina, myocardial infarction, endocarditis, and dyspnea have rarely been reported. The management is controversial and recommendations are based on anecdotal cases or very small retrospective series. A case of a 62-year-old female is reported who presented with chest pain and was found to have myocardial ischemia on SPECT sestamibi. Cardiac catheterization revealed no obstructive coronary artery disease and a large coronary pulmonary fistula communicating from the left circumflex coronary artery to the left pulmonary artery.

Management of coronary artery fistulae. Patient selection and results of transcatheter closure

OBJECTIVES

We report short-term findings in 33 patients after transcatheter closure (TCC) of coronary artery fistulae (CAF) and compare our results with those reported in the recent transcatheter and surgical literature.

BACKGROUND

Transcatheter closure of CAF has been advocated as a minimally invasive alternative to surgery.

METHODS

We reviewed all patients presenting with significant CAF between January 1988 and August 2000. Those with additional complex cardiac disease requiring surgical management were excluded.

RESULTS

Of 39 patients considered for TCC, occlusion devices were placed in 33 patients (85%) at 35 procedures and included coils in 28, umbrella devices in 6 and a Grifka vascular occlusion device in 1. Post-deployment angiograms demonstrated complete occlusion in 19, trace in 11, or small residual flow in 5. Follow-up echocardiograms (median, 2.8 years) in 27 patients showed no flow in 22 or small residual flow in 5. Of the 6 patients without follow-up imaging, immediate post-deployment angiograms showed complete occlusion in 5 or small residual flow in 1. Thus, complete occlusion was accomplished in 27 patients (82%). Early complications included transient ST-T wave changes in 5, transient arrhythmias in 4 and single instances of distal coronary artery spasm, fistula dissection and unretrieved coil embolization. There were no deaths or long-term morbidity. Device placement was not attempted in 6 patients (15%), because of multiple fistula drainage sites in 4, extreme vessel tortuosity in 1 and an intracardiac hemangioma in 1.

CONCLUSIONS

A comparison of our results with those in the recent transcatheter and surgical literature shows similar early effectiveness, morbidity and mortality. From data available, TCC of CAF is an acceptable alternative to surgery in most patients.

Endovascular stent implantation in a coronary artery to pulmonary artery fistula in a patient with pulmonary atresia with ventricular septal defect and severe cyanosis

A 31-year-old male with pulmonary atresia, ventricular septal defect presented with exercise intolerance and severe cyanosis. A restrictive coronary-pulmonary artery fistula was identified as the main source of pulmonary blood flow. We report transcatheter stent implantation in the fistula to augment pulmonary flow as a palliative management option in the adult patient with complex congenital heart disease.

Surgical Treatment of Coronary Artery Fistula

Six patients with coronary artery fistula were treated surgically between October 1977 and November 1998. The clinical manifestations, diagnostic criteria, indications for operation, and surgical techniques were evaluated. One patient died from ventricular fibrillation on the 2nd postoperative day. The outcome for the other 5 patients was good; symptoms and heart murmurs disappeared and all are alive and well after 10 to 21 years of follow-up. It was concluded that analysis of clinical data can confirm the diagnosis and this condition can be treated satisfactorily by suitable surgery.