Coronary artery fistulas: A 12-year single-center experience

Introduction and ObjectivesCoronary artery fistulas (CAFs) are rare abnormalities, often detected incidentally during invasive coronary angiography (ICA). While most are clinically silent, they can cause significant morbidity. We aimed to investigate the clinical, angiographic and management features of CAFs in a population undergoing ICA.MethodsWe retrospectively reviewed the data of all ICAs conducted in our department between May 2008 and January 2020 and selected those with CAFs. Clinical, angiographic, therapeutic and follow-up data were obtained from medical records.ResultsA total of 55 patients with CAFs (35 male, median age 64 years) were identified among 32 174 ICAs. The majority (n=37) had a single fistula. CAFs arose most frequently from the left anterior descending artery (LAD), followed by the right coronary and left circumflex coronary arteries. The most frequent drainage site was the pulmonary artery. Fourteen patients had fistulas originating from both left and right coronary systems. Seven had concomitant congenital cardiovascular disorders. The majority (n=40) were incidental findings. Chest pain was the most common symptom attributable to CAFs and heart murmur the most frequent sign. Conservative management was the main approach (n=40). Eight patients underwent transcatheter closure and seven underwent surgical ligation (six of those during surgery for another heart condition), with no periprocedural mortality.ConclusionsIn our series, the prevalence of CAFs was 0.2%. The majority originated from the LAD and the pulmonary artery was the main drainage site. In patients undergoing intervention, both percutaneous and surgical techniques were safe and effective.     

Concomitant left anterior descending coronary artery and right coronary artery occlusion with typical anterior ST depression and inferior ST elevation

We report the case of a 41-year-old man with acute myocardial infarction showing first ST elevation in V1-V6-DI-aVL leads followed by a typical V2-V4 ST depression (concomitant occlusion of proximal diagonal branch with an incomplete left anterior descending occlusion) and DII-DIII-aVF ST elevation. At coronary angiography, a proximal left anterior descending coronary stenosis with right coronary artery thrombosis was found.     

Progressão ultrarrápida de doença coronária ou placa instável não detetada?

Coronary artery disease rarely manifests itself in the first decades of life, which explains why this population is underrepresented in clinical studies. The mechanisms and natural history of the disease seem to differ between this population and older patients. Recent studies suggest a more rapid disease progression in youth, presenting more unstable atherosclerotic plaques, although this correlation has yet to be proven. In this paper, we present the case of a 41‐year‐old man who presented with a non‐ST elevation myocardial infarction, with percutaneous coronary intervention of the culprit lesion (70–90% lesion at bifurcation of the circumflex artery with the first marginal obtuse artery and a sub‐occlusive lesion of the ramus intermedius). There was also a non‐significant lesion (estimated at 30%) located in the left anterior descending coronary artery. Ten days after discharge, the patient suffered another non‐ST elevation myocardial infarction. The coronary angiography revealed a surprising sub‐occlusive lesion of the left anterior descending coronary artery. Regarding this case, the authors reviewed the literature on the pathophysiology of rapidly progressive coronary artery disease and the approach for non‐significant lesions in patients with acute coronary syndrome, especially in the younger population.     

Electrocardiographic localization of the occlusion site in left anterior descending coronary artery in acute anterior myocardial infarction

BACKGROUND: The site of occlusion of left anterior descending coronary artery is important in acute anterior myocardial infarction because, proximal occlusion is associated with less favorable outcome and prognosis. The present study attempted to evaluate the electrocardiographic correlate of the location of the site of the left anterior descending coronary artery occlusion with respect to first septal perforator and/or the first diagonal branch. METHODS AND RESULTS: The study included 50 patients with a first acute anterior myocardial infarction. The electrocardiogram with the most pronounced ST segment deviation before the start of reperfusion therapy was evaluated and correlated with the left anterior descending occlusion site as determined by coronary angiography. ST segment elevation in lead aVR, ST segment depression in lead V5 and ST segment elevation in V1>2.5 mm strongly predicted left anterior descending occlusion proximal to first septal, whereas abnormal Q wave in V4-6 was associated with occlusion distal to first septal. Abnormal Q wave in lead aVL was associated with occlusion proximal to first diagonal, whereas ST depression in lead aVL was suggestive of occlusion distal to first diagonal branch. For both first septal and first diagonal, ST segment depression > or =1 mm in inferior leads strongly predicted proximal left anterior descending artery occlusion, whereas absence of ST segment depression in inferior leads predicted occlusion distal to first septal and first diagonal. All the patients were followed during their in-hospital stay (median of 7 days), during which four patients in the proximal to first septal and first diagonal group and one patient in the distal to first septal and first diagonal group died (p < or = 0.001). CONCLUSIONS: In acute myocardial infarction electrocardiogram is useful to predict the left anterior descending occlusion site in relation to its major side branches and such localization has prognostic significance.     

Spontaneous coronary artery dissection: a review of the etiology and available treatment options

Spontaneous coronary artery dissection is a rare cause of acute myocardial infarction and sudden cardiac death. We present a case of a 36-year-old female runner who was successfully thrombolysed for acute anterior ST elevation myocardial infarction. Coronary angiography revealed spontaneous dissection of the left anterior descending and diagonal arteries. The patient was treated medically with warfarin and dual antiplatelet therapy. Repeat angiography at 8 weeks showed significant angiographic improvement. Exercise stress testing at 10 months was normal and allowed a return to exercise. At 28 months the patient is asymptomatic and fully active. A review of the etiology and available treatment options is presented.     

Congenital atresia of left main coronary artery

We report a rare case of congenital atresia of left main coronary artery in an elderly male presenting with angina and positive stress thallium test. Coronary angiogram showed absence of left main coronary artery in the left aortic sinus. Collaterals from right coronary artery supplied left anterior descending artery and left circumflex artery territories. Despite collaterals, the left anterior descending and left circumflex arteries were rudimentary. Poor size of left-sided arteries precluded any surgical revascularization which is the treatment of choice in this rare entity.     

Ischemia induced by coronary steal through a patent mammary artery side branch: A role for embolization

Non-occlusion of the internal mammary artery side branches may cause ischemia due to flow diversion after coronary artery bypass grafting.The authors present the case of a 67-year-old man with recurrent angina after undergoing myocardial revascularization with a left internal mammary artery to left anterior descending bypass. He presented with impaired anterior wall myocardial perfusion in the setting of a patent left internal mammary artery side branch. Effective percutaneous treatment was carried out through coil embolization, with improved flow and clinical symptoms, confirmed through ischemia testing.Coronary steal through a patent mammary artery side branch is a controversial phenomenon and this type of intervention should be considered only in carefully selected patients.     

Bifurcating aneurysm of the left main coronary artery involving left anterior descending and left circumflex arteries--a case report.

Coronary artery aneurysm is a rare coronary abnormality, usually diagnosed incidentally by coronary angiography. Major causes of coronary aneurysms include coronary ectasia, Kawasaki disease, and atherosclerosis. Most of the discrete coronary aneurysms are of atherosclerotic origin. The incidence of atherosclerotic coronary aneurysms is about 0.2%, and the left main coronary artery is the least frequently involved artery. Only a few cases of left main coronary artery aneurysm have been reported in the literature, and a left main coronary artery aneurysm involving the proximal segments of the left anterior descending and the left circumflex arteries has not been reported previously. The authors describe this finding in a man who presented with worsening exertional angina pectoris. Coronary angiography demonstrated an aneurysm of the distal left main coronary artery extending into the proximal segments of the left anterior descending and the left circumflex arteries. In addition, a significant flow-limiting atherosclerotic lesion was present in the proximal portion of the left anterior descending artery distal to the aneurysm.     

Bicoronary-pulmonary fistula with aneurysms of the left coronary artery

Bicoronary-pulmonary fistulae are extremely rare cardiac malformations with only ten cases reported. We describe the case of a 46-year-old woman who was referred to our hospital because of a continuum of subfebrile temperature between 37 and 39 degrees C. On chest X-ray there were no signs of right ventricular volume overload or pulmonary congestion, the electrocardiogram showed no abnormalities. Auscultation revealed a 3/6 systolic-diastolic murmur with maximal intensity in the second and third intercostal space at the left parasternal border. At catheterization a coronary-pulmonary fistula of the left coronary artery at the end of the proximal third of the anterior descending branch with an aneurysm of the left main coronary artery and the proximal part of the anterior descending artery was found. Additionally an abnormal conal branch of the right coronary artery was found draining into a venous convolute around the pulmonary artery stem. A left-to-right shunt of 15 percent was calculated. To our knowledge this is the first case report of such a combination of a bicoronary-pulmonary fistula.     

Coronary artery fistulas emptying into left heart chambers

We present three cases of coronary artery fistulas entering into the left heart chambers. Coronary arteriography in one showed aneurysmal dilatation of the main left coronary artery and a fistulous communication with a large left atrium. Exploration during repair revealed an anomalous branch of the left circumflex emptying into the left atrium. In the second case the proximal left circumflex gave rise to a branch supplying a hemangioma which emptied into the left atrium. Coronary arteriograms of the third patient showed an enlarged left anterior descending artery with an anomalous branch emptying into the left ventricle. Shunt flow was estimated with hydrogen as a tracer in the last two cases and was two thirds and one third of the left coronary inflow, respectively. Review of the literature shows 32 previously reported cases of a fistula draining into the left side of the heart.     

An interventional percutaneous approach of posttraumatic left coronary artery fistula repair

We present an interesting case on the management of a traumatic coronary artery fistula in a 39-year-old man who was stabbed by his wife. During emergency sternotomy, left lung and right ventricle injuries were repaired. On the second postoperative day, an acute myocardial infarction of the anterior wall was recognized. Coronary angiography revealed a rare case of a fistula between the left anterior descending coronary artery and the right ventricle of the heart, which was treated by a stent-graft to avoid a re-operation.     

Evaluation of coronary artery anatomy in patients with tetralogy of Fallot by two-dimensional echocardiography

A major coronary artery crossing the right ventricular outflow tract in patients with tetralogy of Fallot interferes with a transannular patch, and preoperative detection of this artery is important. We evaluated the ability of two-dimensional echocardiography to define noninvasively the coronary artery anatomy in 37 consecutive patients (age range, 1 day to 18 years; mean age, 40.9 months). The origin and distribution of the right anterior descending and circumflex coronary arteries, as well as any anteriorly coursing vessel, were examined from parasternal views. Complete studies were obtained in 29 (78%) of the 37 patients. Coronary artery anatomy was determined to be normal by echocardiography in 20 (69%) of the 29 patients. An anterior vessel across the right ventricular outflow tract was detected in the remaining nine patients. Six patients had an anterior descending artery from the left main coronary artery (paired anterior descending arteries in three patients, a right anterior descending artery from the left main coronary artery in two patients, and a right coronary-to-pulmonary artery fistula in one patient). Three patients had no anterior descending artery from the left main coronary artery (anterior descending artery from the right main coronary artery in two patients, and anterior descending and circumflex arteries from the right main coronary artery in one patient). Angiography, surgery, or autopsy confirmed the diagnoses in all but the final patient in whom the anterior descending artery arose from the right main coronary artery as observed at surgery, but the circumflex artery was not seen. Accurate evaluation of coronary artery anatomy is possible by echocardiography in the majority of patients with tetralogy of Fallot. Noninvasive identification of a major coronary artery coursing anteriorly can influence the timing of cardiac catheterization and surgery and the need for angiography.     

Complete proximal occlusion of all three main coronary arteries complicated with a left main coronary aneurysm: a case report

A 68-year-old woman with recurrent chest pain was referred to our institution. Coronary angiography showed 100% obstruction of the left main trunk, the proximal right coronary artery with good collaterals to the left anterior descending artery and left circumflex artery along the conus artery. Emergency surgical revascularization was undertaken with two saphenous vein grafts. The saphenous vein grafts were placed in the left anterior descending artery, obtuse marginal branch and the posterolateral and posterior descending coronary arteries with excellent flow. The postoperative course was uneventful and follow-up angiography was obtained 20 days after the surgery. Coronary angiography demonstrated a saccular aneurysm (10 x 9 mm) originating at the distal segment of the left main coronary artery with 90% stenosis, and excellent patency of both saphenous vein grafts. Follow-up angiography was performed 1 and 3 years after the surgery. The size of the left main coronary aneurysm remained unchanged at both examinations. The patient did well with no further cardiac symptoms after 5 years.     

A case of type IV dual left anterior descending artery associated with anomalous origin of the left circumflex artery in the presence of coronary atherosclerosis

Double origin of the left anterior descending coronary artery (LAD) from the left and right coronary arteries (type IV dual LAD) is a rare coronary anomaly. We report an unusual case of type IV dual LAD associated with anomalous origin of the left circumflex artery from the right coronary artery in a patient with a recent history of myocardial infarction. The first diagonal branch originating from the short LAD demonstrated 70-80% stenosis and the posterior descending artery was totally occluded. We believe that this unusual variance of the coronary arteries in association with atherosclerosis has not been previously reported.     

Spontaneous closure of post-intervention left anterior descending coronary pseudoaneurysm

Coronary pseudoaneurysms are an unusual finding during coronary angiography and there are very little data on their prognosis in the literature. We report the case of a 62-year-old man admitted with an anterior myocardial infarction who developed a pseudoaneurysm in the mid left anterior descending artery some days after a type I coronary perforation during coronary angioplasty. Spontaneous closure of the pseudoaneurysm was observed during hospital follow-up. Spontaneous closure of coronary pseudoaneurysms may be more common in clinical practice than previously thought, but few cases have been reported. As the natural history of post-intervention coronary pseudoaneurysms has been little investigated, reports of their occurrence may help to clarify their evolution.     

Atrial tachycardia treated by coil embolization of a giant coronary artery fistula

Coronary artery fistulas are the second most frequently seen coronary anomaly following abnormalities of coronary artery origin and distribution. A coronary fistula is defined as a direct communication between a coronary artery and any cardiac chamber or vessel. Treatment options include percutaneous embolization and surgical intervention. Herein, we present a case of a giant coronary artery fistula and right atrial tachycardia that was induced during a diagnostic electrophysiologic study but was not inducible after the successful treatment of the fistula. This is the first case indicating this association.     

Spontaneous acquired left descending coronary artery to left ventricle fistula in a patient with an apical saddle thrombus.

Coronary artery fistulas are a rare anomaly. The majority are congenital in origin, although they may be acquired due to invasive cardiac procedures or trauma. The most common course is between the right coronary artery and the right ventricle. The authors describe the case of an acquired left anterior descending coronary artery to left ventricle fistula, associated with a saddle thrombus, in a patient with a previously normal coronary angiogram and none of the predisposing factors mentioned above. Spontaneous formation of acquired coronary fistulas is reported as a very rare event in the literature.     

Spontaneous left main dissection treated by percutaneous coronary intervention

Spontaneous coronary artery dissection is a rare cause of acute coronary events or sudden cardiac death. The clinical presentation is highly variable and prognosis varies widely, depending mainly on how rapidly it is diagnosed. Prompt treatment is also essential, and includes medical management, percutaneous coronary intervention and surgical revascularization.We describe the case of a young woman presenting with spontaneous coronary artery dissection of the left main coronary artery, first diagnosed as coronary thrombus, who underwent successful percutaneous coronary stenting. This report highlights the need to include spontaneous coronary artery dissection in differential diagnosis of chest pain in young women and that distinguishing between coronary thrombus and coronary artery dissection is not always straightforward. To our knowledge this is the fourth case of left main stenting in a patient with spontaneous coronary artery dissection described in the literature.     

Atresia of the proximal right coronary artery in association with coronary artery fistula.

A 2-year-old boy presented for evaluation of a systolic murmur. Echocardiogram demonstrated dilated left main and right coronary arteries. Selective injection of the left coronary artery confirmed dilation of the left main and anterior descending coronary arteries. The left anterior descending coronary artery subsequently filled the mid portion of the right coronary artery retrograde, which emptied into a blind fistula. The orifice of the right coronary artery was atretic, with no filling from the aortic root or the fistula.     

Prediction of the site of total occlusion in the left anterior descending coronary artery using admission electrocardiogram in anterior wall acute myocardial infarction

In anterior acute myocardial infarction, ST elevation in aVL and ST depression in II, III, and aVF predict a culprit lesion in the left anterior descending artery proximal to the origin of the first diagonal branch, with good specificity and positive predictive value. Inferior ST depression is not related to remote ischemia but represents an electrocardiographic phenomenon reciprocal to ST elevation in aVL.