Silent coronary artery-left ventricular fistula: a disorder of the thebesian system?

Congenital coronary artery-left ventricular multiple micro-fistulas and hypertrophic cardiomyopathy: a case report and literature review

Background

Coronary artery-left ventricular multiple micro-fistulas (CA-LVMMFs) is a rare congenital vascular anomaly that may present with no obvious clinical symptoms or a typical angina attack. CA-LVMMFs is usually found unexpectedly during coronary angiography (CAG).

Case presentation

We report a case of a 65-year-old man admitted to the hospital with acute coronary syndrome. CA-LVMMFs was found during coronary angiography. Echocardiography showed apical hypertrophy and blood flow signals were seen in the apical myocardium, connected with the left ventricle. We searched the MEDLINE database and found 39 relevant reports. We made statistics on the clinical characteristics of these patients and found half involved hypertrophy or perfusion defects in the ventricular septum or apex.

Conclusion

As a rare congenital anomaly, the effect of CA-LVMMFs on patients is unclear. By reporting a case and summarizing literature reports, we found that CA-LVMMFs may be associated with myocardial hypertrophy, especially ventricular septal and apical hypertrophy.

Cardiac Structural Changes and Long-Term Survival in Patients With Prominent Thebesian Veins

Although rare, numerous case reports suggest that Thebesian veins confer increased morbidity and mortality. No study has evaluated their effects on cardiac structure or long-term patient outcomes. Patients undergoing coronary angiogram at the study institution from October 2002 and January 2015 were assessed for a diagnosis of prominent Thebesian veins. A matched control group was created and comparisons between clinical, echocardiographic, and survival measures were made. Of 50,116 total patients, 31 (0.06%) were found to have prominent Thebesian veins on angiography and were compared with a matched control group of 596 patients. Patients were matched for age, gender, angiogram date, location and extent of coronary disease, and dominance. Demographic and clinical data were similar between cohorts, with a median follow-up period of 26 months. Patients with Thebesian veins had lower Doppler E wave (0.7 vs 0.8; p = 0.007) and A wave (0.6 vs 0.8; p = 0.001) mitral inflow velocities suggesting some decrease in normal mitral inflow, potentially due to direct shunting into the ventricle from the Thebesian vein network. However, there was no observed difference in left ventricular size or ejection fraction between groups. There was also no significantly increased mortality associated with the presence of Thebesian veins (hazard ratio 1.11, 95% CI 0.58 to 2.13). In conclusion, although previous reports have suggested adverse outcomes from Thebesian veins, our case-control study demonstrated no significant associated adverse cardiac structural changes or increase in mortality, although patients with Thebesian veins were noted to have a decrease in mitral inflow velocities.

Coronary flow characteristics of multiple coronary artery-left ventricular microfistulae in young monozygotic twins

Coronary artery multiple fistulae of the left ventricular chamber are extremely rare congenital malformations. We report on 13-year-old monozygotic twin brothers who have identical abnormalities of coronary flow reserve as well as the same morphological findings of multiple coronary fistulae of the 3 major coronary arteries to the left ventricular chamber. The left circumflex coronary artery (LCX) had abundant fine communications with the left ventricular chamber and had a higher flow rate than the left anterior-descending coronary artery. The coronary flow reserve obtained from the LCX was lower than the normal value matched for the same age group. The increased shunt flow resulted in enlargement of the left ventricular chamber. This is the first report of coronary flow characteristics in children with multiple coronary fistulae.

Bilateral coronary artery fistulas communicating with main pulmonary artery and left ventricle: case report

Coronary artery fistula is an uncommon congenital malformation that generally drains into the main pulmonary artery or the right side of the heart. This is a case report on bilateral coronary artery fistulas communicating with the main pulmonary artery and the left ventricle. A 65-year-old woman was investigated for recurrent chest pain. Coronary angiography revealed this anomalous coronary artery connection without evidence of atherosclerotic coronary artery disease. The rarity of coronary artery fistulas involving both the main pulmonary artery and the left ventricle is emphasized.

Multiple fistulas from the coronary arteries to the left ventricle in tricuspid atresia

It is rare to find multiple fistulas arising from all three coronary arteries and draining into the left ventricle. Coronary angiography revealed this anomaly in a one-year-old girl with tricuspid atresia after conversion to the Fontan circulation. To the best of our knowledge, this is the first report of such multiple fistulas in the setting of tricuspid atresia, and also the first report in childhood.

Coronary artery fistulae from single coronary artery in a patient with rheumatic mitral stenosis

Here we report coronary artery fistulae (CAF) arising from a single coronary artery in a patient with rheumatic mitral stenosis. A 62-year-old woman underwent a coronary angiogram prior to mitral valve replacement (MVR). The left coronary artery angiogram showed the right coronary artery arising from the left anterior descending coronary artery. From the distal left circumflex artery, two CAF were seen draining into left atrium. The haemodynamically insignificant fistulae were left alone and patient underwent MVR. Such an association has not been reported so far.

Myocardial ischemia and infarction due to multiple coronary-cameral fistulae: two case reports and review of the literature

The functional significance of coronary-cameral fistulae, and the effect of these arterial anomalies upon effective coronary blood flow, continue to be debated. Two cases of coronary cameral fistulae, each of which illustrates the likelihood of an ischemic substrate, are herein presented, along with a review of the relevant literature regarding this disorder.

Myocardial ischemia in generalized coronary artery-left ventricular microfistulae

Generalized (multiple) arterio-systemic fistulae are fistulae arising from all three major coronary arteries and drain into the left ventricle are rare and the clinical and hemodynamic sequelae are incompletely understood. This communication is based on the clinical and hemodynamic data of a series of patients (eight cases out of 7262 consecutive patients) incidentally identified at coronary angiography combined with data from cases previously reported in literature. The aim was to assess the role of generalized coronary artery fistulae as a non-atherosclerotic cause of myocardial ischemia by means of a coronary sinus lactate study. Coronary sinus lactate study demonstrated myocardial ischemia in 6/7 patients. Mean arterio-coronary venous lactate difference decreased from 0.31+/-0.18 mmol/l (lactate extraction ratio, LER, 29.4+/-13.9%) at rest to 0.04+/-0.13 mmol/l (LER -4.0+/-13.3%) at peak exercise. Five minutes after cessation of pacing, lactate difference increased to 0.22+/-0.21 mmol/l (LER -20.7+/- 13.2%). At peak pacing stress, 4/7 patients showed frank lactate production, and two patients presented with a reduced cardiac lactate extraction rate also indicating myocardial ischemia metabolically. In the present study, we demonstrated a possible role of a coronary steal mechanism due to microfistulae pathways in the pathogenesis of myocardial ischemia in patients with generalized coronary artery-left ventricular microfistulae.

Intractable vasospastic angina

Images

Three major coronary artery-to-left ventricular shunts: report of three cases and review of literature

Among the congenital coronary artery fistulas, diffuse fistulation into the left ventricular chamber, usually expressed in terms of a coronary artery-left ventricular shunt, is not as rare today as was previously thought. However, the origin of such a shunt from all three major coronary arteries is rare. This paper reports three cases of such an occurrence and presents the clinical features and management of this rare anomaly by analyzing 31 cases, including 28 from the literature.

Multiple coronary artery-left ventricular fistulae: haemodynamic quantification by intracoronary Doppler ultrasound

Multiple coronary artery-left ventricular fistulae involving all three major coronary arteries are extremely rare. Clinical findings are heterogeneous but include a history of typical or atypical angina pectoris in most cases. Coronary arteriography in a 65 year old woman who presented with chest pain at rest revealed multiple fine fistulae arising from the left anterior descending, left circumflex, and right coronary arteries. Left-to-left shunt was estimated by measurements of coronary artery flow velocity with intravascular Doppler ultrasound.

The detection of myocardial ischemia by thallium-201 myocardial scintigraphy in patients with multiple coronary arterioventricular connections

The question of whether myocardial ischemia could be induced in 5 patients with multiple coronary arterioventricular connections by thallium-201 (201Tl) exercise stress myocardial scintigraphy was investigated. Both ST-T changes on ECG and transient myocardial perfusion defects in myocardial scintigrams were observed in 2 patients (40%). In previous reports, all multiple coronary arterioventricular connections, which were shown in angiograms, have been regarded as either Thebesian veins or embryonic sinusoids. However, it is unlikely that Thebesian veins cause myocardial ischemia judging from anatomy. If the vessels cause myocardial ischemia, they should be regarded as multiple coronary arterioventricular fistula. Angiography itself cannot differentiate multiple coronary arterioventricular fistula from Thebesian veins or remnants of embryonic sinusoids. Exercise stress myocardial scintigraphy has a high potential to detect myocardial ischemia due to intracoronary steal. Exercise stress myocardial scintigraphy was used to demonstrate myocardial ischemia in multiple coronary arterioventricular connections. It is concluded that exercise stress myocardial scintigraphy is a reliable test to differentiate multiple coronary arterioventricular fistula from Thebesian veins or remnants of embryonic sinusoids in clinical practice.

Coronary artery-left ventricular communications: a report of two cases and review of the literature

Two patients with chest pain had angiographically-demonstrated communications between the three coronary arteries and the left ventricular chamber. Communications between coronary arteries and the left ventricle are unusual and communications between all three coronary arteries and the left ventricle are rare. These anomalies are, however, commonly associated with symptoms of chest pain. The presence of left ventricular hypertrophy and a widened pulse pressure may suggest a greater hemodynamic effect of the shunt flow than often suspected angiographically.