Bidirectional shunting in a coronary artery-right ventricular fistula associated with pulmonary atresia and an intact ventricular septum

Transcatheter Coil Occlusion of Coronary Artery to Right Ventricular Fistulae in Pulmonary Atresia with Intact Ventricular Septum

We describe a young adult with an underlying diagnosis of pulmonary atresia with intact ventricular septum and Fontan physiology who presented with extreme dyspnoea on exertion. Coronary artery to right ventricular fistulae and reversible myocardial ischaemia secondary to a right ventricular steal phenomenon were present. The right coronary artery to right ventricular fistula was completely occluded with coils, by a transcoronary approach, with amelioration of symptoms. However, one coil embolised and lodged uneventfully in the left atrium during the procedure. This case demonstrates that a transcatheter approach may be successfully employed not only in patients with isolated coronary artery fistulae, but also in patients with coexistent complex congenital heart disease.

Retrograde transcatheter coil embolization of congenital coronary artery fistulas in infants and young children

We report the success of transcatheter coil embolization of congenital coronary artery fistulas in infants and young children, primarily using a retrograde coaxial delivery system. Transcatheter coil embolization of coronary artery fistulas has been used successfully in the adult population with limited reports in the pediatric population, especially in infants. Ten patients underwent transcatheter coil embolization of congenital coronary artery fistulas between January 1993 and August 1999. The median age was 4.5 years (ranging from 5 weeks to 9.8 years). Coils were delivered exclusively using a retrograde arterial approach in 8 of 10 patients. A coaxial system was used in 8 patients. Angiography immediately after placement of coils revealed no residual shunt in any patient. Recent follow-up evaluation is available for 9 patients (median duration of follow-up, 7.9 months). Echocardiographic and clinical evaluations show complete occlusion in 8 of 9 patients. All patients are asymptomatic with normalization of chamber dimensions and coronary artery caliber. Transcatheter coil embolization of congenital coronary artery fistulas can be performed safely and successfully in infants and young children. The use of a retrograde approach and coaxial system is safe and effective and may provide better accuracy, stability and precision for placement of coils.

Pulmonary atresia with intact ventricular septum, antegrade coronary-right ventricular sinusoidal communication, and Wolff-Parkinson-White syndrome

A fenestrated Fontan operation was performed successfully in a patient with pulmonary atresia with intact ventricular septum, an antegrade sinusoidal communication, and Wolff-Parkinson-White syndrome. Unlike most cases, blood flow in the sinusoidal communication was antegrade, from the left anterior descending artery to the right ventricle. This is the first report of the combination of pulmonary atresia with intact ventricular septum and Wolff-Parkinson-White syndrome.

Echocardiographic demonstration of a ventriculocoronary artery communication in a neonate with hypoplastic left heart syndrome

A neonate diagnosed with aortic atresia and mitral hypoplasia had a ventriculocoronary artery communication demonstrated by use of echocardiography. These communications have been noted by angiography and on pathologic specimens in the past, but their clinical importance in the surgical management of these patients remains unclear. The ability to noninvasively identify these communications and study their flow characteristics would help to define their impact on surgical outcome.

Recognition of abnormal connections of coronary arteries with the use of Doppler color flow mapping

Anomalous connection of a coronary artery to a ventricle or pulmonary artery causes shunting of blood from the coronary circuit and may produce myocardial ischemia. Such a coronary anomaly may occur in isolation or with other defects. Doppler color flow mapping and two-dimensional echocardiography were used to diagnose anomalous coronary connections in 13 patients, 1 day to 7 years of age, over a 1 year period. The diagnoses were anomalous origin of the left coronary artery from the pulmonary trunk in five patients, a coronary artery to left ventricle fistula or coronary artery to pulmonary artery fistula in four patients with other complex defects, right ventricular sinusoids in two patients with pulmonary atresia and intact ventricular septum and an isolated coronary artery fistula in two patients. In all cases, the abnormal coronary connection was recognized on the basis of an abnormal, continuous or to and fro flow pattern in the fistula and its connections as demonstrated by scanning in multiple views with Doppler color flow mapping. The low spatial resolution of Doppler color flow mapping limits the anatomic detail available; nonetheless, it is a significant advance in the noninvasive diagnosis of abnormal coronary connections.

Abnormalities of the coronary circulation in pulmonary atresia and intact ventricular septum

To identify developmental aspects and establish morphologic criteria useful for clinical recognition of sinusoids and coronary artery abnormalities in pulmonary atresia and intact ventricular septum, we studied 17 autopsy hearts with this lesion. Hearts from age- and weight-matched infants served as controls. There were two stillborn fetuses, 12 full-term neonates, and 3 infants. None of the eight hearts with normal or large-sized right ventricular chambers had sinusoids or coronary artery abnormalities. Five of nine hearts with small right ventricular chambers had sinusoids; all five lacked trabecular and outlet portions of the ventricle. Four of these five contained major coronary artery abnormalities: atrophy of one or both coronaries proximal to a communication between a sinusoid and the coronary artery. We conclude (1) there is a strong association between the presence of sinusoids and coronary anomalies, supporting the developmental concept of abnormal persistence of embryonic right ventricular sinusoid--coronary artery communications in pulmonary atresia and intact ventricular septum; (2) the absence of trabecular and outlet portions of the small right ventricle indicates a strong possibility of coronary artery abnormalities; and (3) this initial report of a fully-developed lesion in a mid-gestation fetus documents that the coronary artery problem may arise early in fetal life.

Ventriculo-coronary micro-communications in pulmonary atresia and sequential changes of coronary arteries

In the present paper, numerous micro-communications between myocardial sinusoids and small branches of coronary arteries are studied which existed in a rudimentary right ventricle of a female neonate with pulmonary atresia and an intact ventricular septum, who was born on the 40th week of gestation. Cardioangiography revealed a large fistulous subepicardial communication. At autopsy, myocardium of the right ventricle appeared spongy with extensive sinusoid slits. In addition to the large communication which was connecting a deeply extending sinusoid of the right ventricle to the main trunk of the anterior descending artery, numerous micro-communications were found between myocardial sinusoids in the rudimentary right ventricle and intramural small branches of the coronary artery. Furthermore, morphometrical analysis demonstrated that the medias of the intramural arteries in both ventricles of the present case were significantly hypertrophic, as compared with those in the control cases without communications (p less than 0.05). These facts indicate the significance of hemodynamic factors on the persistence of embryonic sinusoid-coronary communication.

Coronary arterial abnormalities in pulmonary atresia with intact ventricular septum

The incidence and severity of abnormalities of the coronary arteries were evaluated in 35 necropsy patients with pulmonary atresia and an intact ventricular septum. Right ventricular to coronary artery fistulous connections were found in more than 60% of the cases. All patients with fistulous connections had histologic abnormalities of the coronary arteries. In 50% the lesions were mild, with medial and intimal thickening producing up to moderate luminal stenosis. In 50% there was loss of normal arterial wall structure and severe narrowing or obliteration of the arterial lumen. The coronary arterial fistulas and histologic abnormalities were prevalent in those with underdevelopment of the tricuspid valve and right ventricular cavity but were not found in patients with a normal or dilated tricuspid valve anulus. The coronary arterial abnormalities were found in more than 80% of patients with a tricuspid valve/mitral valve ratio less than 1. A single coronary artery occurred in 6 patients (17%) of this series. In 80% of those with 1 coronary artery arising from the other, the aberrantly arising coronary artery crossed anteriorly to the pulmonary artery and could be at risk in surgical attempts to reconstruct the right ventricular outflow. Aortography is recommended if the coronary arteries are not clearly delineated on ventricular cineangiocardiography.

Simultaneous patency of ductus arteriosus and surgical shunt in pulmonary atresia with intact ventricular septum. A cause of acute myocardial failure?

Twenty-seven patients with pulmonary atresia and intact interventricular septum were treated with prostaglandin E1 infusion, followed by standard or modified Blalock-Taussig shunt. Three infants died. In all three there was anatomic and functional patency of the ductus arteriosus and the surgical systemic-pulmonary shunt. The unusual clinical course in these cases suggests that in the clinical management of patients with pulmonary atresia and intact interventricular septum after a shunt operation, particular attention must be paid to the problems associated with persistent ductal patency.

Anomalous left coronary artery from the pulmonary artery: significance of associated intracardiac defects

Two patients with anomalous origin of the left main coronary artery from the pulmonary artery had an associated defect (one, critical pulmonary stenosis; the other, ventricular septal defect). They presented with signs and symptoms of the associated defect and the coronary anomaly was unrecognized. Both cases at autopsy lacked the usual large right coronary artery seen with this anomaly. The pathophysiologic features of the combined defects are described, their differences from the isolated anomaly are noted and their relation to surgery is discussed.

Surgical closure of the tricuspid valve for pulmonary atresia, intact ventricular septum, and right ventricle to coronary artery communications

A surgical approach is reported for a patient with pulmonary atresia, intact ventricular septum, and right ventricle to coronary artery communications through sinusoids. A shunt procedure was performed at two days of age; the right ventricular outflow tract was not opened. At subsequent catheterization, the tricuspid valve was temporarily closed with a balloon catheter and no change was seen in the ECG. At five months of age, the right ventricle was plicated and a patch was sewn over the tricuspid valve. One year after surgery, neither the right ventricular cavity nor the sinusoids could be demonstrated at angiocardiography; ECG changes of left ventricular ischemia have resolved, and the child is growing normally.

Right ventricular infarction with cardiac rupture in an infant with pulmonary valve atresia with intact ventricular septum

This report describes an 8 day old infant with pulmonary valve atresia, hypoplastic and hypertensive right ventricle and myocardial sinusoid-left anterior descending coronary artery connections. A large right ventricular sinusoid complex developed that was associated with transmural right ventricular necrosis and cardiac rupture. This is the first report to document transmural myocardial infarction and rupture in pulmonary valve atresia with intact septum, and this condition should be added to the causes of myocardial infarction in infancy. A reduced number of caliber of sinusoid-coronary artery channels may be responsible for right ventricular damage in this condition.

Contributions of intramyocardial sinusoids in pulmonary atresia and intact ventricular septum to a right-sided circular shunt

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