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.     

Transcatheter closure of right coronary artery fistula to the right ventricle

Coronary artery fistula (CAF) is an uncommon anomaly that is usually congenital but can be acquired. Although most patients are asymptomatic, some may present with congestive heart failure, infective endocarditis, myocardial ischemia or rupture. In the past, surgical ligation was the only option in the management of CAF, but since 1983, transcatheter closure of CAF has been increasing as an alternative to surgery. We report a 3-year-old boy, presented in Queen Alia Heart Institute, who underwent successful transcatheter closure of a large fistula communicating the distal part of the right coronary artery to the right ventricle. Our case differs from other CAFs in that the fistula was communicating the right coronary artery itself to the right ventricle.     

Late myocardial infarction after closure of coronary artery fistula

Congenital coronary cardiac fistulae are rare conditions for which surgery is the usual indication. The authors report on the case of one female patient of 28 years with a coronary cardiac fistula responsible for exertional dyspnoea and relapsing pulmonary infections. The diagnosis was suggested by a continuous murmur and was confirmed by Doppler echocardiography and catheterization which showed a dilated, sinuous circumflex artery (2 cm) leading into the right atrium. Surgical closure of the fistula was complicated by an early myocardial infarction and a relapse in the same area with resulting mitral insufficiency. The surgical treatment of coronary cardiac fistulae is widely documented in the literature and recent series demonstrate that good results are usually obtained: however, a late infarction has not been described. The constitution of thrombi in the collateral vessels deriving from the distended vessel probably accounts for the particular evolution noted in this specific case.     

Left ventricular pseudoaneurysm with a fistula to right ventricle following previous repair of septal defect after acute myocardial infarction

A case of left ventricular pseudoaneurysm with a fistula to right ventricle is presented. It appeared following the repair of a ventricular septal defect after acute myocardial infarction. The left ventricular pseudoaneurysm is associated, in most cases, with acute myocardial infarction. However, we should not forget surgery as aetiology of this pathology. The most frequent post-surgery pseudoaneurysms appear after aneurysmectomy and after mitral valve replacement. They tend to develop fistulas which differ from post acute myocardial infarction pseudoaneurysms. Few cases have been described following the repair of septal defect and none of them complicated with a fistula to right ventricle, as in our case.     

Rapid myoglobin analysis to assess coronary artery reperfusion after acute myocardial infarction

Background: Coronary artery reperfusion significantly improves outcome in patients with acute myocardial infarction. A noninvasive method for assessing reperfusion in the early stage of infarction should be helpful in patient management. Hypothesis:We sought to assess whether release pattern of myoglobin is helpful in identifying patients with and without reperfusion following thrombolytic therapy for myocardial infarction. Methods: Myoglobin was measured before thrombolysis, half hourly for 4 h, then every 2 h for 10 h. Myoglobin was analyzed using a ward-based “rapid” and automated analyzer that yielded quantitative results within 10 min of blood collection. Results: In the 15 patients with coronary reperfusion, the time from thrombolysis to peak myoglobin levels (mean ± SD, 2.4 ± 1.5 h) was significantly lower than in nonreperfused patients (5.1 ± 2.9, p < 0.01). As an indicator for reperfusion, a doubling of myoglobin 1 h after streptokinase achieved a sensitivity of 80%, a specificity of 80%, and a predictive accuracy of 80%. Conclusions: The difference in myoglobin release kinetics is useful in identifying patients without coronary reperfusion and should aid in their management.     

Early reperfusion therapy improves left ventricular function after acute inferior myocardial infarction associated with right coronary artery disease

Quantitative global and regional ventriculographic analysis was performed acutely and 1 week later in 46 patients undergoing reperfusion procedures within 6 hours of acute inferior myocardial infarction due to right coronary artery disease. While serial improvement in global left ventricular ejection fraction was not demonstrated for the group, infarct zone regional wall motion did improve (-2.7 +/- 0.9 vs -2.3 +/- 1.4 SD/chord, p less than 0.007). Serial improvement in global ejection fraction was demonstrated in the subgroup of patients treated within 2 hours of symptom onset (55 +/- 10 vs 62 +/- 10%; n = 5; p less than 0.03). Infarct zone regional wall motion improved serially only in the subgroup of patients treated within 3 hours of symptom onset (-2.4 +/- 1.1 vs -1.3 +/- 1.7 SD/chord; n = 11; p less than 0.007). Patients with initially patent arteries had a higher ejection fraction on follow-up catheterization than did those with initially occluded vessels (61 +/- 11 vs 55 +/- 7%; p less than 0.02), and patients with patent arteries at follow-up had a higher ejection fraction than did those whose arteries were occluded (60 +/- 9 vs 48 +/- 4%; p less than 0.0001). We conclude that significant improvement in global and regional left ventricular function in patients with inferior myocardial infarction is possible when reperfusion therapy is begun early or when arterial patency is achieved.     

Percutaneous closure of a congenital coronary artery fistula complicated by an acute myocardial infarction

A coronary artery fistula is not an uncommon finding on a routine coronary angiogram. Small fistulas need no specific treatment, but if haemodynamically important, elective closure is recommended. We present the case of a 69-year-old woman in whom a fistula originating from the right coronary artery and communicating with the right atrium is closed with an Amplatzer VSD occluder. Several hours after a successful closing procedure, the patient developed an acute myocardial infarction. Angiography demonstrated a thrombus that occluded a distal branch of the right coronary artery in the blind pouch of the closed fistula. Urgent bypass surgery was necessary to stabilize the patient's condition. The aim of this case presentation is to warn for complications related to uncommon interventional procedures.     

Right coronary artery aneurysm with fistula to left ventricle: multislice CT appearance

A 34-year-old male presented with prior radiographic evidence of enlargement of the right side of the heart. ECG-gated enhanced multislice CT was performed. Axial source images revealed a diffuse, hugely enlarged right coronary artery (RCA) aneurysm. The distal portion of the RCA flowed directly into the left ventricle (LV), suggesting an RCA to LV fistula. 3D volume rendered images clearly revealed a huge, enlarged RCA aneurysm from the proximal, mid, and distal portions of the RCA. The distal portion of the RCA aneurysm disappeared abruptly without showing distal branching, also suggesting an RCA to LV fistula.     

Double right coronary artery with acute inferior wall myocardial infarction

A double right coronary artery arising from a single ostium in the right sinus of Valsalva is an extremely rare coronary artery variation. We report for the first time in the literature a case of inferior wall myocardial infarction due to a double right coronary artery occlusion that was successfully managed with percutaneous coronary intervention. The rarity of this unusual coronary artery anomaly, its angiographic diagnosis and an important diagnostic dilemma of a high takeoff of a large right ventricular branch are discussed here.     

Routine coronary angiographic follow-up and subsequent revascularization in patients with acute myocardial infarction

The aims of the present study are to: (1) clarify the angiographic follow-up (AFU) rate after discharge; (2) elucidate the characteristics of those undergoing it; and (3) determine the impact of AFU on subsequent revascularization procedures among patients with acute myocardial infarction (AMI). Three thousand and twenty-one consecutive patients presenting within 48 h of AMI onset were enrolled from 17 centers in Japan between January 1999 and June 2001. To clarify the frequency of AFU and their characteristics, 2736 patients who survived at discharge were analyzed. Among 1160 patients matched by propensity score, the impact of AFU on subsequent revascularization was analyzed. Of 2736 patients, 1367 (50%) underwent AFU and constituted the lower-risk population. Of the 580 matched patient pairs, 120 (21%) in the clinical follow-up group and 198 (34%) in the AFU group underwent subsequent revascularization (hazard ratio 7.54; 95% confidence interval 5.74–9.91). Of the 198 patients in the AFU group, 157 (79%) underwent revascularization at the discretion of the responsible physician based on angiographic findings. Angiographic follow-up led to more subsequent revascularization. More evidence would be necessary to determine the effectiveness and the methods by which patients are selected.     

Significance of residual coronary artery stenosis after reperfusion therapy in acute myocardial infarction

We evaluated the efficacy of reperfusion therapy in acute myocardial infarction in terms of postinfarction angina (PIA), reinfarction and coronary reocclusion. In 99 hospitalized patients with acute myocardial infarction within 6 hours after the onset of symptoms, 67 were treated using intracoronary thrombolysis (ICT) alone (Group T) and the remaining 32 using ICT followed by percutaneous transluminal coronary angioplasty (PTCA) (Group T + A). PTCA was performed for the arteries with high grade residual stenosis (TIMI grade 0, 1, 2) after ICT. Recatheterization was performed 28 +/- 12 days after hospitalization in 93% (62/67) of Group T and in all of Group T + A. There were no significant differences in age, sex, time interval from the onset to reperfusion, the extents of coronary artery disease and the Cohn grade of collaterals. However, anteroseptal infarction was more frequent in Group T than in Group T + A (p less than 0.05). Residual stenosis (diameter) at the end of intervention was 81 +/- 14% in Group T, and 48 +/- 15% in Group T + A, (p less than 0.01). Residual stenosis at recatheterization was 70 +/- 23% in Group T, and 55 +/- 22% in Group T + A (p less than NS). The incidence of PIA did not differ between the two groups (20.1% vs 6.2%). However, the incidence was higher in patients with residual stenosis of 70% or more than in those with residual stenosis of less than 70% (23.8% vs 2.9%, p less than 0.05). The incidence of reinfarction (re-elevation of CPK) did not differ between the two groups (7.4% in Group T, 6.2% in Group T + A); and neither did the incidence of coronary reocclusion at the time of recatheterization (14.5% vs 3.1%). We concluded that higher degree of residual stenosis at the end of intervention has a greater risk of PIA and reocclusion. Although differences were not statistically significant, the patients treated with ICT followed by PTCA seemed to have lower incidence of PIA and reocclusion compared with those treated with ICT alone, thus having better hospital prognosis.     

D-二聚体在急性心肌梗死时冠状动脉血栓自溶再通的演变及意义

目的探讨D-二聚体在急性心肌梗死时冠状动脉血栓自溶再通的演变及意义。方法选择4所医院急性心肌梗死(AMI)患者80例,根据治疗方式及冠状动脉造影结果,将患者分为药物溶栓再通组(A组,29例),血栓自溶再通组(B组,30例)及非溶栓组(C组,21例)。各组在治疗前后1、2、4、8、24和48h检测D-二聚体、肌酸激酶同工酶(CK-MB)、肌钙蛋白I、凝血酶原时间等。A组采用重组组织型纤溶酶原激活剂进行静脉溶栓治疗,B组、C组静脉滴注等量生理盐水。结果 3组患者发生AMI后CK-MB和肌钙蛋白I水平均显著增高,与C组比较,A组D-二聚体浓度1、2、4、8h显著升高[(4.31±0.94)mg/L vs(0.89±0.12)mg/L,(5.21±1.06)mg/L vs(1.55±0.43)mg/L,(7.56±1.53)mg/L vs(0.93±0.12)mg/L,(4.33±0.99)mg/L vs(0.61±0.17)mg/L],B组D-二聚体浓度1、2h显著升高[(3.69±0.86)mg/L vs(0.89±0.12)mg/L,(2.39±0.66)mg/L vs(1.55±0.43)mg/L];与B组比较,A组D-二聚体浓度2、4、8、24h显著升高(P<0.05,P<0.01)。C组在相同时间点无显著变化。结论治疗AMI时,D-二聚体浓度变化在药物溶栓再通与血栓自溶再通有显著不同,可作为判断溶栓疗效的指标。