A Tortuous Road for Septic Pulmonary Emboli in Left-Sided Endocarditis

Coronary artery fistulae are rare congenital or acquired connections between the coronary vessels and the cardiac chambers or other vascular structures. We report a case of a woman with mitral valve endocarditis and multiple pulmonary septic emboli. Transesophageal echocardiography revealed a tortuous coronary fistula as the pathway for the septic emboli. The fistula, which originated from the right coronary artery to the right atrium, was visualized using different imaging modalities.     

Facilitated recognition of an undeployed stent with StentBoost

Bilateral coronary artery fistulae originating from both right and left coronary arteries are rare congenital abnormalities that, in the adult population, are often associated with other acquired cardiovascular diseases. We briefly describe a 63-year-old woman with a dual coronary artery fistula and severe aortic stenosis. Both anomalies were successfully corrected surgically.     

Two-dimensional echocardiography of coronaro-cavitary fistulas

4 cases of congenital coronary arteriovenous fistulae in children 20 days to 10 years old were studied by 2D echocardiography. The coronary fistulae were treated surgically in all four cases after biplane aortography and selective coronary arteriography. The visualisation of the coronary arteries was performed by systematic use of several echocardiographic views: - left parasternal short axis view through the aortic root, - apical view, - longitudinal and transverse subcostal views. 3 cases of coronary fistulae between the right coronary artery and a cardiac chamber were diagnosed on the basis of significant dilatation (9 to 12 mm) of the right coronary artery, though the origin and diameter of the left coronary artery were normal. 1 case of a fistulae from a single left coronary artery was not diagnosed despite the demonstration of dilatation of the left main stem. Conversely, there were no false positive 2D echocardiographic diagnoses during the study period. The communication of the coronary fistula to the receiving cardiac chamber was demonstrated in two cases (right atrium: 1 case, left atrium: 1 case, on apical and subcostal views. It was not possible to visualise the communication of the coronary fistula with the right ventricle in the other two cases. 2D echocardiography is a non-invasive method of diagnosing coronary arteriovenous fistulae, but the development of a fistula on a single left coronary artery is a potential source of diagnostic error.     

Multiple coronary artery fistulae communicating through a sinusoid and emptying into the left ventricle

This case report describes the occurrence of multiple coronary artery fistulae emptying into the left ventricle and includes a small communication into the left atrium. The initial diagnosis of a coronary artery fistula was made by standard and nonstandard transthoracic two-dimensional echocardiogram and Doppler interrogation. Later, multiple coronary fistulae communicating through a sinusoid and draining into the left-sided chambers were confirmed by angiography.     

Coronary artery fistula with left or right ventricular communication and sinus-node dysfunction

Coronary artery fistulae that communicate with the left ventricle are quite rare; those accompanied by sinus-node dysfunction are even more unusual. We report 2 cases of congenital coronary-artery-to-left-ventricle fistula with sinus-node dysfunction. In each of these patients, fistulae arose from both left and right coronary arteries. One patient had, in addition, a right coronary artery fistula that communicated with his right ventricle. Sinusnode dysfunction encountered in these 2 patients was likely caused by chronic general ischemia arising from a steal syndrome associated with the fistulae.     

Transcatheter coil occlusion of coronary artery to right ventricular fistulae in pulmonary atresia with intact ventricular septum

We describe a young adult with an underlying diagnosis of pulmonary atresia with intact ventricular septum and Fontan physiology who presented with extreme dyspnoea on exertion. Coronary artery to right ventricular fistulae and reversible myocardial ischaemia secondary to a right ventricular steal phenomenon were present. The right coronary artery to right ventricular fistula was completely occluded with coils, by a transcoronary approach, with amelioration of symptoms. However, one coil embolised and lodged uneventfully in the left atrium during the procedure. This case demonstrates that a transcatheter approach may be successfully employed not only in patients with isolated coronary artery fistulae, but also in patients with coexistent complex congenital heart disease.     

A rare combination of LMCA fistula to left superior vena cava with drainage into the coronary sinus in a 74-year-old woman

Coronary artery fistulae are rare anomalies in which a communication is present between a coronary artery and either a cardiac chamber or another vascular structure, such as the pulmonary artery or coronary sinus. Most fistulae are congenital in origin, but they can also occur as a result of chest trauma or endocardial biopsy. The presence of a fistula is a rare occurrence in itself, but the different origins and drainage sites of fistulae are what make them even more rare. We report the case of a 74-year-old woman with a history of progressive congestive heart failure who was found to have a large left main coronary fistula draining into a persistent left superior vena cava to a markedly dilated and aneurysmal coronary sinus.     

Transcatheter Closure of a Coronary Fistula with an Amplatzer? Vascular Plug: Should a Retrograde Approach Be Standard?

Coronary artery fistulae are rare disorders. Only 2 reports in the medical literature discuss the use of vascular plugs to occlude coronary fistulae, and the same device-the Amplatzer Vascular Plug-was deployed via different techniques to treat those patients. The safety, the feasibility, and the standard approach to deployment have yet to be established. Herein, we describe the case of a 15-year-old boy who presented with a continuous murmur at the left sternal border. The patient was diagnosed with a large coronary fistula that originated from the right coronary artery and emptied into the right atrium. He underwent transcatheter closure of the fistula. We placed a 14-mm Amplatzer Vascular Plug into the narrowest part of the fistula, which resulted in complete occlusion and an excellent outcome. Our retrograde approach is simple and obviates the need to establish arteriovenous loops or to insert additional devices, such as coils. In this report, we compare our results with those of the 2 previous reports. To our knowledge, this is only the 2nd report that describes the closure of a coronary fistula in an adolescent patient by use of an Amplatzer Vascular Plug.     

Congenital coronary fistulas: the most frequent congenital coronary anomaly

Congenital arteriovenous coronary fistulae are a rare condition of a direct communication between a coronary artery and one of the cardiac chambers, the coronary sinus, the superior vena cava or the pulmonary artery. In most instances the diagnosis is made during heart catheterization for coronary or congenital heart disease. Whether congenital coronary artery fistulae should be treated by transcatheter intervention or surgery and in which patients fistula closure should be performed is controversial. This report summarizes our experience of the surgical treatment of congenital arteriovenous coronary fistulae in 14 patients at the Deutsches Herzzentrum Berlin between March 1988 and April 1997. There were seven females and seven males aged from 3 to 67 years (mean 47 years). We analyzed the symptomatic status (NYHA class) preoperatively and in the late outcome, the preoperative angiographic data and the surgical techniques. The right coronary artery was affected in six, the left in six, and both arteries in two cases. The fistulae drained into the pulmonary artery in eight cases, into the superior vena cava and into the right atrium in two cases, and into the right ventricle and into the coronary sinus once. Fistula closure was unsuccessfully attempted interventionally in two patients and surgically in one patient in another institution. Twelve of the patients exhibited additional cardiac disease requiring surgery: seven cases presented additional coronary artery disease, one mitral valve disease, one persistent ductus arteriosus, one an aneurysm of the right coronary artery, and two an atrial septal defect. We performed fistula closure either by ligating or transsecting the fistula as well as by closure of the fistula's drainage opening. Surgery and postoperative courses were uneventful in all patients. Most of the patients (93%) were in good clinical condition (NYHA I-II) after a mean follow-up period of 6.6 years (range 3-11). Fistula closure should be performed in patients who are symptomatic or who have a hemodynamic relevant shunt. In asymptomatic patients and small left-to-right shunt, fistula closure should also be performed to prevent later complications. Surgical fistula closure should be employed in patients with larger and more complex fistulae, especially if interventional therapy failed, and for patients with additional cardiac conditions that necessitate surgery.     

Left-circumflex coronary artery to right atrium fistula with saccular aneurysm and its endovascular treatment

The combination of coronary artery aneurysm and coronary artery fistula is infrequent. A saccular aneurysm of a branch of the left-circumflex coronary artery associated with multiple fistulae to the right atrium was observed on a coronary angiogram performed in a 47-year-old female. Multidetector computed tomography coronary angiography detailed the anatomy of the abnormal coronary artery. An embolization with a microcoil was performed and the aneurysm sac was excluded.     

Coronary-pulmonary artery fistula arising distal to obstructive coronary lesions.

We report 2 cases of coronary-pulmonary artery fistulae (CPF) arising distal to obstructive coronary artery disease. The fistula in the first patient was in the form of a tortuous dilatation of the distal portion of the right coronary artery and opened into the right pulmonary artery. In the second case, the fistula, a plexus of vessels, arose from the left anterior descending artery and entered the left pulmonary artery. Both the fistulae were successfully ligated at the time of concurrent coronary artery bypass graft surgery.     

Spontaneous closure of an iatrogenic circumflex coronary artery-to-coronary vein fistula

Coronary artery fistulae are rare and usually discovered as incidentally during coronary angiography. They may be congenital or acquired secondary to trauma or cardiac intervention, and usually involve the left anterior descending or right coronary artery, with the circumflex artery much less often affected. They have been reported in transplanted hearts, usually as a secondary complication to right ventricular biopsies, and typically drain into the right ventricle. We hereby report a case of circumflex coronary artery to the great cardiac vein fistula that we believe occurred after transplantation and spontaneously closed while we were assessing the patient for percutaneous closure of the fistula.     

Another cause of chest pain: Coronary artery—Pulmonary artery fistulae

This report describes three patients with coronary artery fistula from proximal left anterior descending artery to the pulmonary artery. Retrospective analysis of 2756 adults undergoing coronary arteriography for evaluation of angina pectoris between July 1988 and January 2000 revealed coronary artery fistulae in three patients: one male (46 years old) and two females (45 and 53 years old). No murmur was audible in any patient. There was no associated significant coronary artery disease. The feeder arteries to the fistulae for all three patients were left anterior descending coronary artery. One of the patients underwent cardiopulmonary bypass and the fistulae was ligated, due to very strong angina. The diagnosis is mostly incidental during routine coronary arteriography. We concluded that the coronary artery-pulmonary artery fistula might be a cause of angina without audible murmur and may sometimes need surgical ligation.     

Single Coronary Artery with Right Ventricular Fistula: Case Report and Literature Review

We report a rare case of a 6-year-old boy who was diagnosed with coronary artery fistulae communicating with the right ventricle and a left single coronary artery. Preoperative angiography showed a dilated and tortuous single coronary artery draining into the right ventricle. Two coronary artery fistulae draining into the right ventricle were detected at operation and both of these were ligated. Postoperative angiography showed that the single coronary artery diameter was almost normalized, although the vessel was still slightly tortuous. His clinical course was uneventful. In this report, we summarize cases of coronary artery fistula with single coronary artery that have been reported in the literature as well as our case.     

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.     

Iatrogenic ST Elevation during Percutaneous Closure of a Coronary Artery Fistula

Coronary artery fistulae are an uncommon anomaly and, while frequently asymptomatic, may require interventional therapy. Transcatheter approaches for closure of coronary artery fistulae are now commonly used, with various methods of fistula occlusion described, including detachable coils. During a percutaneous procedure to occlude a symptomatic left anterior descending coronary artery to pulmonary artery fistula, the patient experienced chest discomfort with anterior ST segment elevation. We demonstrate an unusual, unique and striking ECG abnormality complicating the delivery of coils designed to occlude the fistula in the absence of coronary artery injury. The mechanisms of the procedural ECG changes are discussed, as are potential alternate diagnoses and associated therapy.     

A young female with an unusual cause of dyspnea

Within the context of coronary artery anomalies, coronary fistulas are classified by termination. A coronary artery fistula (CAF) involves a sizable communication between a coronary artery and a heart chamber (coronary-cameral fistula) or a segment of the systemic or pulmonary system (coronary artery arteriovenous fistula). These are often due to deviations from normal embryological development. CAF may be present in patients at any age, but is usually suspected in early childhood and accounts for 0.08-0.4% of congenital cardiac anomalies. They may also be acquired by trauma or from invasive cardiac procedures. The majority of CAF arises from the right coronary artery (55%) and the left anterior descending coronary artery, with the circumflex rarely involved. The outcome of these connections depends upon the termination site. The pathophysiology of these lesions is identical. Coronary artery anomalies are difficult to detect clinically. Most are benign but some may produce symptoms that can be life threatening. We present a female with an unusual cause of dyspnea found to have a continuous heart murmur, cardiac catheterization showed an evidence of a long tract arising from the origin of the right coronary artery with flow directed towards the right atrium and the right atrial appendage.     

Acquired right coronary artery fistula draining to the right ventricle: angiographic documentation of first appearance following reperfusion after acute myocardial infarction,with subsequent spontaneous closure

Most coronary artery fistulae are congenital in origin but have been reported to be acquired as complications of chest trauma, coronary angioplasty, or rupture of a coronary artery aneurysm. This is the first angiographic documentation of a coronary fistula acquired after myocardial infarction that subsequently closed spontaneously during follow up.     

Closure of a coronary fistula with a transcatheter implantable coil

Large sized coronary artery fistulas are rare and diagnosed in only 0.05% of adult catheterized patients. Only a minority of these fistulas are operated upon. We describe a percutaneous technique to close a left coronary artery fistula draining into the right atrium in a 30-yr-old male patient. The fistula was closed by implantation of a trefoil coil, inserted through a catheter selectively advanced into the fistula.