冠状动脉瘘──国内报道67例的临床分析

目的：冠状动脉瘘虽属少见疾病，但临床上易和其他先天性心脏病混淆而造成误诊。本研究旨在提高对该病的认识以减少误诊率。方法：作者报告３例冠状动脉瘘并综合国内文献共６７例，皆经心血管造影或手术确诊。对其病理解剖、临床表现、实验室检查和手术结果进行统计分析。结果：本组冠状动脉篓起源于左、右和双侧冠状动脉者分别为１７、４９和１例。临床上无特征性症状，瘘口在右心系统者多有连续性杂音（３０／３２），而在左心室者无一例连续性杂音（０／６）。本组手术治疗５７例，手术晚期死亡１例，４２例随访３个月至２５年，其中１例症状恶化，４１例症状改善。结论：本病血液动力学改变与瘘口大小及部位有关，改变明显者出现心肌缺血和心脏扩大，升主动脉造影和选择性冠状动脉造影有重要诊断价值。对有明显临床及血液动力学异常者应行手术治疗。     

先天性冠状动脉瘘5例治疗体会

总结先天性冠状动脉瘘５例手术治疗体会。作者认为：冠状动脉瘘虽为罕见先天性心脏畸形,但手术安全,效果良好。非手术治疗远期可发生心肌缺血、心肌梗死、冠状动脉瘤破裂等并发症。故一经确诊,均宜手术治疗。手术方法以体外循环下切开瘘口所在心腔或冠状动脉缝闭瘘口为宜。冠状动脉造影可确定瘘口位置,具有确诊价值。     

先天性冠状动脉畸形11例报告

报告经冠状动脉造影或手术证实的单纯性先天性冠状动脉畸形11例,约占同期580例冠状动脉造影的1.6％。本组冠状动脉畸形病变分两大类:①冠状动脉瘘8例,含右冠状动脉右室瘘6例;②冠状动脉起源异常3例。指出冠状动脉瘘需与其他先天性心脏病鉴别,心脏B超对诊断有一定的帮助,冠状动脉造影为确定诊断的重要手段;对大的冠状动脉瘘应及时手术治疗。     

先天性冠状动脉瘘的外科治疗

目的总结外科手术治疗冠状动脉瘘的临床经验及治疗方法，以提高对该类疾病的治疗效果。方法对2001年2月至2011年11月收治的104例先天性冠状动脉瘘患者的临床资料进行回顾性分析，其中男性48例，女性56例，年龄5个月至71岁，平均年龄34岁。104例中有56例患者在非体外循环下行直接结扎及缝扎，其中微创小切口14例；48例合并其他先天畸形及心脏疾病者在体外循环下施行手术，直接结扎及缝扎瘘口，对合并的心脏畸形或疾病同期做相应的矫治。结果瘘口发生于右冠状动脉63例，发生于左冠状动脉41例，瘘人右心房21例，瘘人右心室40例，瘘人肺动脉30例，瘘人冠状静脉1例，瘘入上腔静脉1例。除1例因其他疾病死亡外，全组无手术死亡。随访2-10年，复查超声均无异常。结论先天性冠状动脉瘘可采用直接结扎及缝扎方法，部分病例可采用小切口治疗，手术效果安全有效。     

彩色多普勒超声诊断先天性冠状动脉瘘的应用

目的探讨彩色多普勒在诊断先天性冠状动脉瘘(CAF)中的价值。方法应用彩色多普勒对12例超声诊断冠状动脉瘘的患者进行检查分析。结果 12例冠状动脉瘘患者全部经升主动脉及选择性冠状动脉造影检查证实,其中3例接受手术治疗。按冠状动脉来源分组,右冠状动脉来源7例,左冠状动脉来源5例;按冠状动脉瘘开口位置分,右心室瘘5例,右心房瘘2例,肺动脉瘘3例,左心室瘘2例。结论彩色多普勒对开口于心腔及肺动脉内的先天性冠状动脉瘘具有特征性的表现对诊断有应用价值。     

迂曲的左冠状动脉-左心室瘘介入治疗一例

先天性冠状动脉瘘(CAF)在冠状动脉造影中的检出率为0.016%～0.020%[1],约90%CAF止于右心系统,止于左心房、左心室的仅占10%[2].近30年已有许多文献报道用介入法治疗CAF[3-6],但有关左冠状动脉-左心室瘘介入治疗的报道罕见.     

冠状动脉瘘的外科治疗

本文报告７例先天性冠状动脉瘘的诊断和治疗经验，并对其发病规律、解剖特点、手术指征、手术方式和手术技巧进行讨论。冠状动脉瘘一旦确诊应尽早手术。发现瘘口、严密缝扎、防止遗漏是手术治疗的关键。     

52例先天性冠状动脉瘘的外科治疗

目的　总结 5 2例先天性冠状动脉瘘的外科治疗效果。方法　全组 5 2例中 ,年龄 9个月～ 5 8岁 ,平均 (15 7± 16 4)岁。 36例为单纯的先天性冠状动脉瘘 ,16例合并有其他心脏外科疾病。5 2例中 ,右冠状动脉瘘占 71 2 % ,左冠状动脉瘘占 2 8 8%。瘘口于右室 ,右房 ,左室 ,左房及肺动脉分别为 42 3% ,30 8% ,11 5 % ,5 8%和 9 6 %。结果　手术均在体外循环下进行 ,10例切开冠状动脉闭合瘘口 ,2 6例经心腔闭合瘘口 ,16例分别闭合在冠状动脉内和在心腔内的瘘口 ;16例合并其他心脏病变同期矫治。心腔内发现二个瘘口者有 6例 ,三个瘘口者 3例 ,余 43例为单一瘘口。全组无死亡及残余漏。 37例随防 1个月～ 8年 ,平均 3 5年 ,均无症状。一例有ST T改变。结论　外科治疗先天性冠状动脉瘘是安全和有效的方法 ,合并有其他心脏外科疾病应同时矫治。准确判断瘘口的位置和确切可靠的缝合技术是防止残余漏的关键。     

中老年人先天性冠状动脉瘘19例临床分析

目的：总结我院中老年人先天性冠状动脉瘘的I临床特点及治疗方法。方法：对19例先天性冠状动脉瘘患者病史、心电图、X线胸片、超声心动图、选择性冠状动脉造影和治疗方法及结果进行回顾性分析。结果：17例经超声心动图检查，确诊15例；12例行选择性冠状动脉造影均确诊(其中包括超声心动图确诊的8例)；经导管弹簧圈栓堵治疗5例，外科手术治疗10例。随访3个月至7年均存活，无不适症状。结论：先天性冠状动脉瘘一经确诊，应积极治疗，首选介入治疗，即经皮弹簧圈栓堵术，其方法可靠、创伤小、方便、有效、安全；其次可选择外科手术治疗，也是可靠、有效、安全的方法。     

成人先天性细小冠状动脉瘘特点及分型研究

目的研究成人先天性细小冠状动脉瘘(small coronary artery fistula,sCAF)的临床和冠状动脉造影特点,并探讨依据直径分型新标准。方法回顾性分析2003年9月至2017年12月昆明医科大学附属延安医院收治接受冠状动脉造影的成人先天性sCAF患者的临床表现、冠状动脉造影及血流动力学等资料。分析瘘道直径与是否接受手术治疗的关系,评估瘘道直径水平预测sCAF手术治疗的可能性,并计算界值。结果研究入选158例sCAF患者,女66例(41.77%),男92例(58.23%),年龄(44.94±17.35)岁,4例(2.53%)有先天性心脏病家族史,11例(6.96%)合并其他先天性心脏病。胸闷等疑似心绞痛发作和心悸等心律失常发作是主要症状,二者共占36.70%,心房颤动为最常见的心律失常表现形式(8.86%)。左冠状动脉前降支-肺动脉瘘是最多见的瘘道(41.14%),其次为右冠状动脉-肺动脉瘘(25.32%)。大部分瘘道呈不同程度迂曲,且合并局限性狭窄和(或)扩张,继发病变最多见是动脉瘤形成(38.61%)。瘘道直径为(2.78±1.14)mm,肺动脉平均压(pulmonary artery mean pressure, PAMP)为(16.66±5.63)mmHg(1 mmHg=0.133 kPa),肺循环和体循环流量比值(flow ratio of pulmonary to systemic, Qp/Qs)为1.07±0.13。以瘘道直径中位数分组,直径较大组需要手术可能性较大(P0.05)。Logistic回归分析结果显示sCAF瘘管直径与是否需要手术治疗正相关。受试者工作特征曲线分析结果显示最佳界值为2.91 mm(敏感性为78.6%,特异性为85.3%)。结论成人先天性细小冠状动脉瘘自具特点,起源于左冠状动脉前降支及瘘入肺动脉最多见,瘘道直径2.91 mm可作为细小分型的潜在最佳界值。     

经心导管法封堵冠状动脉瘘的临床分析

目的探讨经心导管法封堵先天性冠状动脉瘘的技术方法、疗效和安全性。方法对6例先天性冠状动脉瘘患者进行了经心导管法封堵治疗，其中男2例，女4例，年龄5—39岁(平均14．4岁)。选择性主动脉和冠状动脉造影见右冠状动脉右室瘘3例，右冠状动脉右房瘘1例，左冠状动脉右房瘘2例。结果采用pfm弹簧圈和COOK弹簧栓子堵塞3例，Amplatzer蘑菇伞封堵3例，均获成功。3例直接将封堵器封堵瘘口；另外3例用260cm交换导丝经导管通过瘘口至右心房，用网套导管套住交换导丝并拉出股静脉，送人传送器至瘘口上方，选择不同的封堵器封堵，观察心电图正常，重复主动脉造影或冠状动脉造影无分流后释放。结论冠状动脉瘘已往均采用外科手术修复，我们选用可控弹簧圈和Amplatzer蘑菇伞封堵获得成功，提示介入疗法具有较高的治愈性，操作安全，疗效可靠。     

Outcomes of transcatheter embolization in the treatment of coronary artery fistulas.

Thirteen children (seven male) with coronary artery fistula underwent percutaneous transcatheter occlusion. The age range was 8 months to 14 years (mean, 6.3 years). The fistulas had their origins from the right coronary artery (six), from the left anterior descending coronary artery (three), and from the left circumflex coronary artery (four). Drainage was to the right ventricle (seven), the right atrium (three), and one each to the pulmonary artery, left atrium, and superior caval vein. The fistulas were closed with coils in 10 patients, a Rashkind double-umbrella device in 1 patient, and an Amplatzer Duct Occluder in 2 patients. Complete occlusion was achieved in 9 of 13 patients. Complications consisted of migration of coils in four and transient arrhythmias or changes in the resting electrocardiogram in four patients. Follow-up studies 1 to 31 months (mean, 14.6 months) after occlusion noted only four patients with trivial (clinically insignificant) residual shunts. Owing to various coronary fistula morphologies, transcatheter occlusion requires availability of different embolization techniques. Short-term follow-up supports persistent clinical efficacy and transcatheter closure techniques as the initial form of therapy.     

经导管弹簧圈栓堵法治疗先天性冠状动脉瘘

目的　探讨经导管弹簧圈栓堵冠状动脉瘘的安全性和有效性。方法　总结我院 1999年 5月至 2 0 0 2年 12月 6例 38～ 70岁 (平均年龄 5 0 7岁 )的先天性冠状动脉瘘进行栓堵治疗的患者 ,其中冠状动脉瘘由左冠状动脉至肺动脉 2例、右冠状动脉至肺动脉 2例、右冠状动脉至右下肺静脉及双侧冠状动脉至肺动脉各 1例。结果　 5例 (83 3% )栓堵后完全闭合 ;1例因瘘管迂曲 ,导管到位困难而放弃介入治疗。无手术死亡及并发症。 5例患者经体检和超声心动图随访 3～ 4 6个月 ,无残余瘘 ,无复发。结论　经导管弹簧圈栓堵先天性冠状动脉瘘不用开胸 ,病人易接受 ,安全、有效、方便 ,可作为治疗冠状动脉瘘的一种方法。     

Transcatheter embolization in the treatment of coronary artery fistulas

Seven patients with a coronary artery fistula underwent percutaneous transcatheter embolization (five were male and two female; the age range was 2 to 67 years [median 17]). Three patients were symptomatic. The left to right shunt ranged from 1.6 to 2.6:1. In six patients, the fistula was an isolated congenital anomaly; in one, it was acquired. The fistula arose from branches of the left (n = 5) and right (n = 2) coronary arteries and drained to the right ventricle (n = 2), right atrium (n = 2), coronary sinus (n = 1), pulmonary artery (n = 1) and a bronchial artery (n = 1). Different embolization techniques were used to occlude eight feeding arteries. The embolization materials included a detachable balloon (n = 3), coaxial embolization with platinum microcoils (n = 3), a combination of detachable balloon and microcoil (n = 1) and standard steel coils (n = 1). Satisfactory occlusion was achieved in six patients. In one case, the valve of the detachable balloon was damaged, resulting in early balloon deflation and a residual fistula. There were no associated complications in any patient. Follow-up investigation by Doppler ultrasound or coronary angiography 4 months to 4 years later showed that permanent occlusion was achieved in all six patients in whom embolization was initially successful. Transcatheter embolization should be considered the treatment of choice for coronary artery fistulas.     

Congenital coronary artery fistula draining into the right ventricle: successful surgical closure after failed transcatheter coil embolization

Coronary artery aneurysms and fistulae are very rare congenital anomalies. They occur in 0.2-0.4 % of all congenital heart diseases. In this article, we report a case of a four-year-old girl with a right coronary artery aneurysm and fistula draining into the right ventricle. Since the transcatheter coil embolization was not successful, surgical occlusion was considered in this case. We describe and discuss the handling of the fistula and the aneurysmatic enlargement of the proximal coronary artery.     

Successful transcatheter coil embolization of coronary artery fistula in an infant

Congenital coronary artery fistula is a rare anomaly that can cause several types of morbidity as well as mortality. Recently, transcatheter coil embolization for congenital coronary artery fistula has been advocated as an effective alternative to surgical repair and is associated with a low morbidity and good clinical outcome. We report a 49-day-old infant who had tachycardia, tachypnea, prolonged and interrupted feeding, cardiomegaly, and continuous murmur, and who underwent successful transcatheter coil embolization for a congenital right coronary artery fistula. At review 1 year after coil occlusion showed that serial plain chest radiographs, myocardial enzyme analysis, electrocardiography, and wall motion on echocardiography were normal.     

经导管介入治疗冠状动脉瘘

目的：探讨经导管介入治疗冠状动脉瘘的方法及临床疗效。方法：经导管堵塞冠状动脉瘘14例，平均年龄7．1岁。结果：13例应用弹簧圈堵塞，平均瘘口大小为3．65mm，除3例失败外均获成功；1例（瘘口6．6mm）应用Amplatzer动脉导管未闭堵塞器堵塞成功。所有病例随访1个月－4年，均无残余分流及任何并发症。结论：经导管介入治疗冠状动脉瘘具有良好的临床疗效及安全性。可控弹簧圈一般用于堵塞瘘口较小的冠状动脉瘘，而瘘口较大的冠状动脉瘘可选用Amplatzer动脉导管未闭堵塞器。     

Transcatheter closure of coronary artery fistulas

BACKGROUND: Transcatheter closure of coronary artery fistulas has emerged as a successful alternative to surgery. We describe various techniques and short-term findings in 15 patients who were taken up for transcatheter closure of these fistulas. METHODS AND RESULTS: Fifteen patients (aged 2-55 years; 12 males) with coronary artery fistulas underwent percutaneous transcatheter closure between June 1997 and December 2002. Site of origin of these fistulas were: right coronary artery in 7, left anterior descending coronary artery in 4, left main coronary artery in 2 and left circumflex coronary artery in 2 patients. Drainage site of these fistulas were: right ventricle in 9, right atrium in 4 and pulmonary artery in 2 patients. Out of these 15 fistulas, 14 were congenital and one was iatrogenically produced following inadvertent cutting balloon angioplasty of a septal perforator in a patient with chronic total occlusion of left anterior descending coronary artery. Various occlusion devices used to close these fistulas were: conventional metallic coils in 10, floppy tips of coronary angioplasty guidewires in 2, Amplatzer duct occluder in 1 and Amplatzer septal occluder in 2 patients. One of our patients had a coronary artery fistula draining by two openings into the right atrium, both of which were successfully closed using 2 Amplatzer duct occluders. Check angiogram after the procedure revealed complete occlusion in 13 (86.6%) and small residual flow in 2 patients. Follow-up studies at 3-55 months (mean 18 months) showed complete abolition of shunt in all patients with no evidence of recanalization leading to recurrence of shunt. CONCLUSION: Transcatheter closure of coronary artery fistulas is feasible and safe in the anatomically suitable vessels. Use of floppy tips of coronary angioplasty guidewires reduces the cost of the procedure significantly. which is an important consideration in developing countries like India.     

Transcatheter closure of coronary artery fistulas.

Transcatheter closure of a coronary artery fistula was undertaken in nine patients. There were three fistulas from the left circumflex coronary artery to the coronary sinus, three from the left anterior descending coronary artery to the right ventricular apex, two from the right coronary artery to the superior vena cava/right atrial junction and one fistula from the left circumflex artery to the pulmonary artery. The fistula was closed with Gianturco coils in six patients, a double-umbrella device in two and a combination of an umbrella and coils in one patient. All fistulas are completely occluded. Complications consisted of migration of two coils, one of which was retrieved, and a transient junctional tachycardia in one patient. In an additional three patients with multiple coronary artery fistulas, transcatheter occlusion was not attempted.     

A Rare Case of Transcatheter Closure of Both Inlet and Outlet of a Left Coronary Artery-to-Left Ventricular Fistula with Giant Coronary Artery Aneurysm

A congenital coronary artery fistula (CCAF) combined with giant coronary aneurysm (CAA) is a rare congenital cardiac abnormality. We reported an 8-year-old patient who underwent transcatheter closure of both inlet and outlet of a proximal left coronary artery (LCA)-to-left ventricular (LV) fistula with CAA of 41 mm × 28 mm in diameter, during which acute occlusion of left anterior descending coronary artery (LAD) occurred immediately after device implantation at the inlet of fistula. We managed to prevent the patient from major adverse cardiac events by conservative therapy with dual antiplatelet agents instead of surgical removal of the device. The patient recovered well and had been follow-up for 2 years with no late complications reported.