Echocardiographic Diagnosis of a Right Coronary Artery-Coronary Sinus Fistula

In this case report, we describe a 67-year-old woman with right coronary artery-coronary sinus fistula. This woman had complaints of chest pain. Ischemic ECG changes and a ventricular tachycardia were detected on her electrocardiogram. Transthoracic echocardiography showed a large right coronary artery and a dilated coronary sinus. Drainage of the coronary artery to the coronary sinus was detected by colour flow mapping during transesophageal echocardiographic examination, and a 94 mmHg peak gradient was recorded by continuous wave Doppler at the drainage site. These findings were confirmed by cardiac catheterization. Transthoracic and transesophageal echocardiography can provide definitive confirmation of the right coronary artery-coronary sinus fistula, and can be the diagnostic procedure of choice when this anomaly is suspected.     

Congenital coronary artery fistulas in adults: concomitant pathologies and treatment

Background Coronary artery fistula is a rare congenital malformation. Complications such as intracardiac shunts, endocarditis, myocardial infarction, aneurysm and sudden death can be observed. The purpose of this article is to present our experience with concomitant cardiac pathologies and discuss various therapeutic approaches including surgical and percutaneous intervention. Materials and methods During 18,272 diagnostic cardiac catheterizations, coronary artery fistulas were identified incidentally in 10 patients (0.05%). There were 3 female and 7 male patients. The patients’ ages ranged from 42 to 76 years. All patients with coronary artery fistula were preoperatively in New York Heart Association functional class and Canadian Cardiovascular Society class II or III. Results In addition to coronary artery fistula, coronary artery disease was detected in 4 patients (40%), a ventricular septal defect and an aneurysm of the sinuses of Valsalvae with aortic regurgitation in one patient (10%) and an anomalous origin of the LAD from the pulmonary trunk in one patient (10%) during cardiac catheterization. Four (40%) of the total of 10 patients had only coronary artery fistula. Surgical closure of the coronary artery fistula was performed in 7 patients (70%). An interventional fistula closure with a coil device was confirmed by cardiac catheterization in another 3 patients (30%). One patient of the latter group showed a small residual shunt from the LAD to the pulmonary trunk. No death or long-term morbidities could be observed. Conclusions Coronary artery fistulas are incidentally diagnosed during coronary artery angiographies in adults and should be closed to prevent complications.     

A case of coronary artery fistula with mitral stenosis

Coronary artery fistulae, being a rare form of congenital anomalies of the coronary arteries, are usually discovered by chance during coronary arteriography. However, these fistulae can cause an important coronary morbidity and mortality leading to angina, syncope, congestive heart failure, myocardial infarction and sudden death. The coincidence of mitral stenosis and congenital artery fistula is rare in the literature. In our case report, a patient with a coronary artery fistula originating from the circumflex, draining to the main pulmonary artery, discovered at cardiac catheterization and coronary angiography done with a prediagnosis of mitral stenosis is presented in the light of the literature.     

IntraCameral right coronary artery: detection by 64 slice coronary computed tomographic angiography and implications for radiofrequency ablation of atrial dysrhythmias

An intracameral or intracavitary course for a coronary artery is a rare anomaly. Nevertheless, it carries a significant impact for invasive cardiac procedures that require right atrial catheterization, pacemaker implantation, or electrophysiologic study such as radiofrequency ablation. If a coronary artery were to be damaged within the atrial chamber by catheter manipulation at the time of heart catheterization, serious complications might ensue. We describe the first reported case of an intracameral right coronary artery identified with multidetector 64-slice coronary computed tomographic angiography performed prior to pulmonary venous antral isolation for atrial fibrillation.     

Effective long-term surgical management of congenital coronary artery fistulas

Congenital coronary artery fistula (CAF) is a rare anomaly involving communication between the coronary artery and any cardiac chamber. We retrospectively studied 23 patients with CAF who were surgically treated at 2 institutes over the past 38 years. All patients had continuous murmur and were diagnosed using echocardiography and cardiac catheterization. Eighteen patients had no other heart anomalies, and 5 had an associated anomaly. Fifteen patients were treated using cardiopulmonary bypass via differential surgical approaches (6 patients, CAF orifice closure through cardiac chamber; 6, coronary arteriotomy for CAF orifice closure; and 3, CAF ligation). Eight patients underwent CAF ligation without cardiopulmonary bypass. CAF originated from the right coronary artery in 11 patients; the left coronary artery in 10, and both arteries in 2. Drainage occurred at the following sites: the right ventricle (10 patients), right atrium (6), left ventricle (4), left atrium (2), and pulmonary artery (1). All surgeries were performed through a median sternotomy. There were no mortalities during or after the hospital stay. Aortic root replacement was performed in 1 patient 30 years after the CAF surgery. Three of the 6 patients who underwent coronary arteriotomy for CAF orifice closure showed coronary artery occlusion at the distal coronary arteriotomy site with long-term collateral formation. Surgical management of CAF was thus effective, resulting in 100% long-term survival and closure rates. Dilated CAF-associated vessels have been normalized for the long term. CAF should be therefore considered even in asymptomatic patients because of the risk of future complications.     

Right coronary artery to left ventricle fistula—Effective diagnosis with 64-MDCT

Coronary artery fistula is a rare congenital anomaly in which a communication is present between a cardiac chamber or another vascular structure. In this paper, we describe a 52-year-old asymptomatic male patient with a right coronary artery to left ventricle fistula. We demonstrate the effectiveness of 64-MDCT (Multi-detector row computed tomography) in demonstrating the precise anatomy of this fistula in which transthoracic echocardiography was inadequate for evaluation.     

Right coronary artery-coronary sinus fistula diagnosed by three-dimensional echocardiography

Right coronary artery-coronary sinus fistula is a very rare congenital anomaly in which a right coronary artery fistula drains into the right atrium, right ventricle, or pulmonary artery. A right coronary artery-coronary sinus fistula was diagnosed in a 44-year-old man by three-dimensional echocardiography and confirmed by computed tomography angiography and surgery. Relevant published experience in diagnosing this kind of anomaly is summarized.     

Fistulous communication between the right coronary artery and left atrium.

This report describes congenital coronary artery fistula of the right coronary artery draining into the left atrium in a young woman. The initial diagnosis of this rare anomaly was made noninvasively by echocardiography. Transesophageal echocardiography was vastly superior to transthoracic echocardiography in presenting the entire course of the fistula. The diagnosis was confirmed by coronary angiography. The fistula was successfully closed surgically.     

Prenatal diagnosis of a right coronary artery to right atrial fistula with a giant coronary artery aneurysm: A case report

Coronary artery fistula (CAF) is a rare cardiac anomaly. Here, we diagnosed a right coronary artery-right atrium fistula with giant coronary artery aneurysm (CAA) via fetal echocardiography at 35 weeks' gestation. An urgent caesarean delivery was performed at 36 weeks' gestation because CAA caused mitral obstruction, and fetal atrial flutter was present. Following delivery, we performed aneurysm ligation because the new-born developed atrial tachycardia. The intraoperative findings confirmed the sonographic findings. To the best of our knowledge, prenatal ultrasound diagnosis of CAF and giant CAA has not been reported in the literature. We focus on the ultrasonic characteristics and differential diagnosis in this literature.     

Doppler Echocardiographic Features of Coronary Artery Fistula: Report of 8 Cases

Coronary artery fistula is a rare congenital anomaly in which the involved coronary artery empties into a cardiac chamber, pulmonary artery, or other structure. Its diagnosis can be made noninvasively by finding a dilated coronary artery by 2-dimensional (2D) echocardiography, and its drainage can be detected by color flow mapping. We describe features of coronary artery fistulas in 8 patients whose condition was prospectively diagnosed by Doppler echocardiography with color flow mapping. The right coronary artery was involved in 4 cases and the left coronary artery in 4. Four fistulas drained to the right ventricle, 2 to the right atrium, and 2 to the pulmonary artery. In 1 patient who had left and right coronary fistulas to the pulmonary artery, only the first was diagnosed noninvasively. The diagnosis of coronary fistulas can usually be made by 2D echocardiography with color flow mapping. However, fistulas to the pulmonary artery may be more difficult to detect by 2D echocardiography because the coronary artery may be of normal size and the shunt small. (J Am Soc Echocardiogr 1999;12:149-54.)     

Combined coronary and perfusion cardiovascular magnetic resonance for the assessment of coronary artery stenosis.

The purpose of this study was to evaluate the feasibility and accuracy of combined coronary and perfusion cardiovascular magnetic resonance (CMR) in the assessment of coronary artery stenosis. Thirty-five consecutive patients (27 men, eight women, age range 34-81 years), undergoing cardiac catheterization, were assessed with 3D coronary CMR and rest-stress perfusion CMR. Significant coronary stenosis was determined by vessel narrowing or signal loss with coronary CMR, and by abnormal contrast enhancement with perfusion CMR. Coronary artery diameter stenosis greater than 50% was considered significant with conventional cardiac catheterization. Seventeen patients had significant coronary artery disease, and in these there were 35 significant stenoses on cardiac catheterization. All left main stem arteries were normal on both cardiac catheterization and coronary CMR. For the diagnosis of coronary artery stenosis, coronary CMR had a sensitivity of 92% for the left anterior descending artery (LAD), 79% for the right coronary artery (RCA), but only 13% for the circumflex coronary artery (LCX). Perfusion CMR had corresponding sensitivities of 69%, 86%, and 63%, respectively. For all arteries the accuracies for coronary and perfusion CMR were 67% and 72%, respectively. Combining coronary and perfusion CMR improved the accuracy to 77%. These data demonstrate that in patients with suspected coronary artery disease, combined coronary and perfusion CMR is feasible, increases the accuracy of detection of significant coronary stenosis, and offers the possibility of combined anatomical and hemodynamic assessment of coronary artery stenosis.     

Anomalous coronary arteries of aortic origin

Anomalous coronary arteries cause only uncharacteristic symptoms and are therefore often an incidental finding during conventional coronary angiography, with an incidence of 0.3-0.8%. The commonest anomaly is an aberrant origin of the main left or right coronary artery from the wrong sinus of Valsalva. Rarely there is a fistula draining into one of the cardiac cavities (right ventricle, right atrium, left ventricle or, rarely, superior vena cava) or displaced connection, as seen in anomalous origin of coronary artery from the pulmonary artery, resulting in a left-to-right shunt. In congenital heart disease, especially Fallot's tetralogy, the incidence of abnormal coronary arteries may be 2% or more. The proximal course in the former category may be misdiagnosed in up to 50% of cases. Aortic root injection with subtraction angiography, further detailed investigation with transoesophageal echocardiography or magnetic resonance angiography are therefore required as these have potential implications on subsequent surgery. Because of the abnormal course between aorta and pulmonary artery/outflow tract of the right ventricle and acute angulation there is a risk of angina, acute myocardial infarction or sudden death during or after exercise. It is therefore important to identify the exact cardiac anatomy, particularly in patients undergoing angioplasty, stenting or cardiac surgery.     

Screening angiography of supraaortic vessels performed by invasive cardiologists at the time of cardiac catheterization: indications and results

An aging population makes multiple vascular distributions more likely in patients arriving at the cath lab for coronary artery angiography or complete cardiac catheterization. Whether or not screening angiography of supraaortic vessels can be performed at the time of cardiac catheterization by the invasive cardiologist is still debatable. We sought to determine safety and utility of performing angiography of supraaortic vessels during cardiac catheterization. Medical records of all patients undergoing combined coronary and noncoronary angiography between May 1998 and December 2002 was retrospectively reviewed. One hundred and forty patients (80 males, mean age 67.8 ± 5.4 years) underwent combined cardiac catheterization and angiography of supraaortic vessels. Carotid artery angiography was performed at the same time of cardiac catheterization in 62 patients and subclavian artery angiography in the other 78 patients. Significant findings were reported in 32 (22.8%) patients. Complications included 1 transient ischemic attack and 2 carotid spasm resolved with nitrates infusion. In most cases the same standard catheters used during coronary angiography were used also for noncoronary angiography (119 patients, 85%). The incidence of significant angiographic findings and the relatively frequent association of CAD with supraaortic vessel atherosclerosis supports combined cardiac catheterization and angiography of supraaortic arteries but only in patients with multivessel coronary artery disease.     

Prenatal diagnosis of ventriculocoronary fistula.

BACKGROUND: Cardiac anomalies may be associated with abnormal coronary vascular connections. We report the prenatal diagnosis of ventriculocoronary fistula in three fetuses with associated cardiac anomalies. MATERIALS AND METHODS: Fetal echocardiography was performed in three patients referred for suspected cardiac anomaly. Two-dimensional fetal echocardiography was complemented by color Doppler flow imaging and spectral Doppler in all cases. RESULTS: A ventriculocoronary fistula was diagnosed in three patients referred at 22, 23 and 32 weeks. The first patient had hypoplastic left heart associated with transposition of the great arteries and pulmonary atresia with an intact interventricular septum. The coronary fistula arose from the transposed aorta to the left ventricle. In two patients ventriculocoronary fistula was found in association with pulmonary atresia and an intact interventricular septum. In all cases there was bidirectional flow within the fistula (diastolic blood flow towards the ventricle with reversal during ventricular systole). The pregnancy with hypoplastic left heart with transposition, and one of those with pulmonary atresia resulted in neonatal death and stillbirth, respectively. In the third instance the ventriculocoronary fistula was verified by postpartum cardiac angiography. The infant initially received a Blalock-Taussig shunt, subsequently replaced by a bidirectional Glenn shunt, and was doing well at the time of writing. CONCLUSION: A ventriculocoronary fistula can be identified prenatally by color and spectral Doppler. This anomaly should be sought in fetuses with outflow tract obstructive cardiac lesions and an intact interventricular septum. Prenatal diagnosis allows early angiography postnatally. Delineation of coronary vascular regions may therefore facilitate preoperative planning.     

Congenital coronary artery fistulas in Turkish patients undergoing diagnostic cardiac angiography

A coronary artery fistula is a direct communication between a coronary artery and one of the cardiac chambers or vessels around the heart. The present study was undertaken to define the incidence, clinical findings and angiographic characteristics of congenital coronary artery fistula in Turkish adults who underwent diagnostic cardiac angiography. A consecutive series of 11,350 coronary angiography, performed between January 2000 and December 2001, was retrospectively examined for the presence of coronary artery fistulas. The incidence of congenital coronary artery fistulas was 0.08%. All the patients had chest pain during exertion or at rest. All the fistulas were single and most arose from the proximal left anterior descending coronary artery and drained into the pulmonary artery. All the fistulas were small. Surgical treatment was not indicated. A congenital coronary artery fistula in adults is a distinct though rare entity, variable in its incidence and commonly associated with coronary artery obstructive disease. Diagnosis is mostly incidental during routine coronary angiography.     

先天性冠状动脉畸形的冠状动脉造影研究

目的：探讨冠状动脉畸形的特征及评价选择性冠状动脉造影在诊断中的作用。方法：回顾性研究总结2024例患者的冠状动脉造影资料，并确诊各种先天性冠状动脉畸形。结果：2024例冠状动脉造影中检出42例冠状动脉畸形。9例冠脉起源异常；先天性冠状动脉瘘检出33例；冠状动脉—肺动脉瘘24例，右冠状动脉左室瘘4例，右冠状动脉右室瘘1例，左冠状动脉右室瘘1例，前降支左室瘘2例，回旋支左室瘘1例。9例经手术证实。2例冠状动脉—肺动脉瘘予介入栓塞治疗。结论：冠状动脉畸形是少见的先天性心血管畸形，选择性冠状动脉造影是确诊的重要手段。     

先天性冠状动脉瘘的影像学诊断

目的：研究动脉造影对先天性冠状动脉瘘的价值及结合文献分析及其病理解剖。材料与方法：先天性冠状动脉瘘6例,男4例,女2例,年龄5－55岁,平均28．3岁,6例患者均行彩色多谱勒,X线片及动脉造影检查;3例行外科手术治疗。结果：动脉造影发现右冠状动脉右室瘘2例,右冠状动脉右房瘘1例,左冠状动脉右房瘘1例,左冠状动脉左房瘘和左冠状动脉冠状静脉瘘各1例,结论：先天性冠状动脉瘘临床表现无特征性,动脉造影是对该病诊断的可靠方法,彩色多谱勒及X线片为该病的辅助诊断方法。     

电子束CT技术诊断冠状动脉瘘的临床应用价值

目的 探讨冠状动脉瘘的电子束CT（EBCT）征象。方法 对经EBCT工手术证实的10例冠状动脉瘘行回顾性分析。本组男7例，女3例，年龄2岁至55岁，中位年龄为48岁。EBCT检查均采用单层增强扫描。结果 EBCT提示6例右侧冠状动脉扩张迂曲，其中5例与扩大的心室腔沟通，另1例近段与主肺动脉沟通；4例冠状动脉瘘源于左侧冠状动脉，其中1例左侧对角支粗大，局部囊状扩张钙化，与左室腔沟通，2例左侧圆锥支与主肺动脉连接，最后1例左侧冠状动脉主干及回旋支扩张钙化，后者经左房前间隙经后壁与右房沟通。结论 EBCT提示冠状动脉及其分支扩张迂曲，与心腔或其他血管异常沟通，应首先考虑冠状动脉瘘。     

ST Elevation in the COVID-19 Era: A Diagnostic Challenge

BackgroundSevere acute respiratory syndrome coronavirus 2 induces a marked prothrombotic state with varied clinical presentations, including acute coronary artery occlusions leading to ST-elevation myocardial infarction (STEMI). However, while STEMI on electrocardiogram (ECG) is not always associated with acute coronary occlusion, this diagnostic uncertainty should not delay cardiac catheterization.Case ReportsWe present 2 cases of patients with COVID-19 that presented with STEMI on ECG. While both patients underwent cardiac catheterization, a delay in time to intervention in the patient found to have acute coronary artery occlusion may have contributed to a poor outcome.Why Should an Emergency Physician Be Aware of This?These cases highlight the fact that while not all COVID-19 patients with STEMI on ECG will have acute coronary artery occlusions, there is continued need for prompt percutaneous coronary intervention during the severe acute respiratory syndrome coronavirus 2 pandemic.     

Coronary artery bypass graft surgery in a patient with ureterosigmoidostomy

A 75-year-old male patient had stable angina pectoris. After coronary angiography we decided to perform a coronary artery bypass graft surgery. Twenty years ago the patient underwent radical cystectomy and bilateral ureterosigmoidostomy because of bladder cancer. After that, his micturition was via the rectum. We did not experience that before. As is known, monitoring of urine output is very important after cardiac surgery. The patient was consulted with an urologist for how to monitor urine output in him. Transrectal catheterization was recommended for our follow-up, but before the catheterization bowel cleansing is necessary. Four-vessel on-pump coronary artery bypass graft surgery was performed without any problem. Peroperative urine volume and arterial blood gas results were normal. Urine output is a sensitive variable reflecting the patient’s effective blood volume and tissue perfusion. Urinary catheterization is a standard for all cardiac surgeries, and it allows the patients’ urine to drain freely from the bladder for collection. Monitoring of urine output in patients with ureterosigmoidostomy is impossible by standard urinary catheterization method. In this case we performed transrectal catheterization for Urine flow follow-up. Urine flow follow-up is essential after the open-heart surgery and it can be measured in different ways, as in our case.