Traumatic aortic dissection and coronary fistula treated with transcatheter management.

An adolescent male presented with a dissection of the thoracic aorta and a left anterior descending coronary artery to right ventricular fistula following a road traffic accident. Authors report the management of this patient using a transcatheter approach for both these arterial issues, with stenting to the thoracic aorta and coil embolization of the coronary artery to right ventricular fistula as a staged procedure, along with a brief review of the literature on traumatic arterial injuries.     

Transcatheter coil embolization of iatrogenic coronary artery–left ventricle fistula after mitral valve replacement

Acquired causes of coronary fistulas are rare disorders and may develop following coronary atherosclerosis, infection, or trauma (iatrogenic). Iatrogenic coronary fistulas may be acquired secondary to surgical or nonsurgical interventions. We describe a case of an iatrogenic coronary artery–left ventricle fistula following mitral valve replacement surgery, presented with ventricular arrhythmia and heart failure. In a unique technique, we implanted three coils with the aid of a Scepter C balloon with inflation at the ostial portion of the left circumflex artery.     

Acquired coronary artery fistula after open heart surgery for congenital heart disease

BACKGROUND: Most coronary artery fistulas were reported as congenital. Acquired coronary artery fistula occurring after cardiac surgery has rarely been reported. METHODS: From 1998 to 2003, 10 patients with coronary artery fistula detected by echocardiography after open heart surgery for congenital heart disease were included. Their ages ranged from 2 months to 41 years (median 4.2 years). The underlying heart disease was tetralogy of Fallot in five patients, ventricular septal defect in three, double chamber right ventricle in one, and transposition of the great arteries with ventricular septal defect in the remaining one. RESULTS: Of these 10 patients, the coronary artery fistula originated from the left coronary artery in four, right coronary artery in two, and unknown origin in the remaining four. The coronary artery fistula drained into the right ventricle in nine and into the left ventricle in the remaining one. The incidence of acquired coronary artery fistula after open heart surgery for congenital heart disease was 0.44% (8/1832). The identified risk factors for acquired coronary artery fistula were reoperation and right ventricular muscle resection in ventricular septal defect. After follow-up for 0.5-12 years (mean 4.1+/-3.3 years), the coronary artery fistula persisted, but neither symptoms nor significant left-to-right shunt was noted. CONCLUSIONS: Acquired coronary artery fistula is a rare complication after cardiac surgery. Reoperation and resection of right ventricular hypertrophic muscle increase the risk of this complication. Although shunt flow did not increase during follow-up, the significance of acquired coronary artery fistula needs further investigation.     

Postoperative iatrogenic left coronaroventricular fistula. Demonstration by color two-dimensional Doppler

The authors report the case of an asymptomatic 67 year old patient, in whom, 6 years after aortic valve replacement, Doppler color flow mapping showed the presence of a coronary artery--left ventricular fistula. The normality of preoperative coronary angiography suggested that this fistula was created during peroperative left ventricular purging: the implantation of a needle through the right ventricle and interventricular septum. A iatrogenic lesion of a septal branch probably caused the communication between the left anterior descending artery and the left ventricle. Postoperative normalisation of the left ventricular end diastolic dimension, the absence of dilatation of the left main coronary on 2D echocardiography, the narrowness of the Doppler color jet and the absence of a significant end diastolic Doppler signal in the aortic isthmus indicated a fistula of small size and simple Doppler echocardiographic follow-up was decided upon.     

Two cases of coronary artery-left ventricular fistula associated with left ventricular hypertrophy]

Two cases of coronary artery-left ventricular fistula (AVF) associated with left ventricular hypertrophy were reported. The first patient was a 53-year-old man with chest pain. Selective coronary angiography (CAG) revealed bilateral coronary arteries draining into the left ventricle (LV). The second patient was a 46-year old man with electrocardiographic (ECG) abnormalities. CAG showed bilateral coronary artery which communicated via a maze of fine vessels into LV. In both cases, ECG showed ST depression and inverted T wave, and two-dimensional echocardiography revealed hypertrophic cardiomyopathy (HCM). Coexistence of coronary artery-left ventricular fistula and HCM seems to be a casual association.     

Successful transcatheter coil embolization of coronary artery to left ventricular fistula associated with absent pulmonary valve with tricuspid atresia in early infancy.

Transcatheter coil embolization for coronary artery to left ventricular fistula was successfully performed in a neonate. At 30 weeks' gestation, fetal echocardiography showed a hypoplastic right ventricle with intact ventricular septum, absent pulmonary valve, tricuspid atresia, and marked distension of the right coronary artery. After birth, the neonate had congestive heart failure and the electrocardiogram showed myocardial ischemic changes in the left ventricular area. Aortography showed a dilated right coronary artery arising from the ascending aorta and draining into the left ventricle. Transcatheter coil embolization was carried out on the 9th day after birth. Since the procedure, no myocardial ischemic changes have been detected. Transcatheter coil embolization is a useful therapy for coronary artery fistula associated with myocardial ischemia.     

“Wedge effect” in stenosed coronary artery assessed using a PressureWire

In this case report, we describe the recovery of abnormal coronary pressure waveform using a PressureWire Certus during percutaneous coronary intervention in a patient with severe stenosis in the proximal segment of the left anterior descending coronary artery. Since the diastolic pressure in the distal left anterior descending coronary artery was lower than that in the aorta, the pressure waveform before percutaneous coronary intervention represented the left ventricular pressure through a fistula due to a “wedge effect” in the stenosis as if the pulmonary artery wedge pressure determined by a Swan–Ganz catheter reflected the pressure in the distal portion (left atrium). We diagnosed this case coronary artery-left ventricular fistula based on the above findings. PressureWire Certus may be a valuable tool with which to estimate the hemodynamics in a patient with a coronary anomaly.     

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.     

Diagnosis of a right coronary artery-left ventricular fistula by cross sectional and Doppler echocardiography

A case of right coronary to left ventricular fistula was diagnosed by cross sectional and Doppler echocardiography. The origin and site of entry into the left ventricle of the enlarged right coronary artery were shown by cross sectional echocardiography. Diastolic flow was detected in the left ventricle by both pulsed and continuous Doppler echocardiography. The fistula was confirmed by cardiac catheterisation and was successfully closed at operation.     

Coronary artery-left ventricle fistula after PTCA: diagnosed by contrast echocardiography

A coronary artery fistula is a rare complication following percutaneous transluminal coronary angioplasty (PTCA). It may result in communication with either the left or right ventricle. Previous reported cases were diagnosed by coronary angiography using contrast medium. We present a case with a septal coronary artery fistula to the left ventricle following PTCA that was diagnosed by contrast echocardiography.     

Evaluation of Coronary Artery Fistula by Color-Flow Doppler Echocardiography

An asymptomatic newborn infant with a left coronary artery to right ventricular apex fistula was evaluated using color-flow Doppler techniques. Color flow mapping during diastole showed a prominent turbulent flow signal that could be traced from the proximal left coronary artery, along the interventricular septum, to the right ventricular apex. Color flow Doppler is an important complement to two-dimensional imaging for the identification and location of coronary artery fistulas.     

Diagnosis of a right coronary artery-left ventricular fistula by cross sectional and Doppler echocardiography.

A case of right coronary to left ventricular fistula was diagnosed by cross sectional and Doppler echocardiography. The origin and site of entry into the left ventricle of the enlarged right coronary artery were shown by cross sectional echocardiography. Diastolic flow was detected in the left ventricle by both pulsed and continuous Doppler echocardiography. The fistula was confirmed by cardiac catheterisation and was successfully closed at operation.     

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.     

Traumatic aneurysm of left anterior descending coronary artery with fistulous opening into left ventricle and left ventricular aneurysm after stab wound of chest: Report of case with successful surgical repair

A patient survived a stab wound of the heart, and an aneurysm of the left anterior descending coronary artery developed with a fistulous communication into the left ventricle and a postinfarction ventricular aneurysm. All lesions were successfully repaired by surgery 4 years later. Preoperatively the patient suffered from angina pectoris presumably due to a coronary arterial “steal syndrome” and recurrent myocardial infarction presumably due to coronary embolism from thrombi formed within the coronary aneurysm. The combination of a coronary arterial aneurysm and a coronary arterial-left ventricular fistula produced a diastolic murmur that disappeared after surgery.     

Single coronary artery-right ventricular fistula

We report a rare case of a male child aged 4 years and 5 months who was diagnosed with a coronary artery fistula and left single coronary artery. Pre-operative evaluation with echocardiography and selective angiography showed a dilated and tortuous single coronary artery draining into the right ventricular outflow tract. The coronary fistula was ligated. The post-operative and clinical courses were uneventful.     

Evaluation of coronary artery fistula using a color Doppler flow imaging technique

Two unusual cases with coronary artery fistula were reported. The diagnoses were first made by color Doppler flow imaging and confirmed by selective coronary angiography and operation. In the first case, color Doppler revealed a continuous flow signal within the dilated left coronary artery and a turbulent jet within the right atrium. In the second case, color Doppler showed turbulent flow signals which could be traced from the proximal left coronary artery, along the left ventricular posterior wall and into the left ventricle. The high velocities at the site of drainage of fistula were recorded by the continuous-wave Doppler and the calculated pressure gradient confirmed that the abnormal flow was from the systemic circulation. We are of the opinion that color Doppler flow imaging is a reliable technique for detecting coronary artery fistula and the combination of color Doppler with continuous-wave Doppler is essential for evaluating the hemodynamics of the shunt flow.     

Pulmonary atresia with intact atrial and ventricular septums, unroofed coronary sinus, and absent aortocoronary arterial connections

A stillborn fetus with pulmonary valvar atresia and intact atrial and ventricular septums also had absence of coronary arterial connections from the aorta and an unroofed coronary sinus. A left superior caval vein drained to the dilated coronary sinus. The left coronary artery was anomalously connected to the proximal branch of the right pulmonary artery, and a fistula from the right ventricle supplied the right coronary artery.     

Coronary artery-right ventricular fistula in a patient with heart transplantation. A complication of endomyocardial biopsy

Two cases of coronary artery right ventricular fistula were diagnosed during the yearly check-up of 38 of the 66 cardiac transplant patients of the Montreal Heart Institute between September 1982 and April 1989. In one case, the fistula involved the right anterior ventricular branch of the right coronary artery and in the other case, a septal branch of the left anterior descending artery. Histological examination of the biopsy fragments obtained before diagnosis of the fistula showed the presence of small calibre arteries, which was not the case in 10 control transplant patients. A review of the literature indicates that the risks of endomyocardial biopsy are minimal (less than or equal to 0.5%). However, the possibility of a coronary artery right ventricular fistula should be added to the list of known complications. The resulting shunt is negligible and has no haemodynamic consequences.     

Two giant renal aneurysms and renal arteriovenous fistula associated with cardiac insufficiency and a sustained elevation of atrial natriuretic peptide and brain natriuretic peptide

A 64-year-old man presented with chief complaints of exertional dyspnea and palpitation. He had previously undergone left nephrolithotomies twice. A chest roentgenogram showed pleural effusion on both sides with cardiac dilation, and electrocardiography showed a frequent occurrence of ventricular premature contractions. An echocardiogram showed diffuse hypokinesis of the left ventricular wall motion (ejection fraction, 45%) and dilation of the left ventricle (left ventricular end-diastolic dimension, 61 mm). We administered diuretics, ACE inhibitors and a beta-adrenergic blocking agent after making a diagnosis of cardiac insufficiency. Because coronary angiography showed 90% stenosis of the left anterior descending coronary artery (No. 7), we performed coronary angioplasty in this locus. Though both the left ventricular wall motion and ejection fraction improved, and the clinical symptoms disappeared, the left ventricular end-diastolic dimension, and arrhythmia did not improve. Furthermore, the brain natriuretic peptide increased despite these treatments. Thereafter, a left renal artery aneurysm (extrarenal aneurysm measuring 5 cm in diameter and an intrarenal aneurysm measuring 3 cm in diameter) and a left renal arteriovenous fistula were discovered when abdominal echography was performed because of epigastric discomfort. As a result, a left total nephrectomy was performed. Subsequently, the left ventricular end-diastolic dimension and arrhythmia improved, and the brain natriuretic peptide returned to a normal value. We herein report a case that developed cardiac insufficiency due to a renal aneurysm and renal arteriovenous fistula after undergoing left nephrolithotomies twice.     

Coronary artery fistulas in pulmonary atresia and ventricular septal defect

Pulmonary atresia with ventricular septal defect is an anomaly with highly variable anatomy. Rarely, a coronary artery-to-pulmonary artery fistula may contribute to pulmonary blood flow. Since 1996, we have treated 4 patients with coronary-pulmonary fistula associated with pulmonary atresia and ventricular septal defect. Two fistulas originated from the left coronary, one from the right coronary, and one from a right-sided solitary coronary system. All terminated in the main pulmonary artery, which was adequate in all cases. The fistulas were managed by direct internal closure. Total intracardiac repair was then accomplished in all patients at the same sitting. There was one death. In children with favorable anatomy, direct closure of the fistula from the pulmonary artery is adequate and allows single-stage intracardiac repair.