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Coronary arteriovenous fistulas are an abnormal conduit between a coronary artery and another cardiovascular lumen, without an intervening capillary bed. The reported prevalence is 0.002-0.3%. Physiologic consequences such as congestive heart failure, coronary steal phenomenon and fistula aneurysm formation and rupture are possible. There are limited reports of symptomatic coronary arteriovenous fistulas in association with pregnancy. We describe a 19-year-old woman with symptomatic left circumflex artery to coronary sinus fistula, terminating into a large exophytic varix in the right atrium, presenting for an elective caesarean section at 37 weeks gestational age. Our anaesthetic management strategy aimed to optimise myocardial perfusion, maintain euvolemia, avoid right ventricular obstruction from exophytic varix and avoid sympathetic stimulation or sudden increases in pulmonary vascular resistance. A slowly titrated epidural was used as the primary anaesthetic. Our patient tolerated the procedure well and was discharged home on postoperative day two. Understanding of the potential physiologic consequence of coronary arteriovenous fistulas, and interaction with the physiologic changes of pregnancy and delivery, are essential for the management of these cases.
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We present a case of a coronary arteriovenous fistula between the left circumflex (LCX) and the atrium with LCX ectasia. Four months after surgical closure of the fistula, the patient experienced acute myocardial infarction caused by thrombosis in the LCX. Antiplatelet drugs were replaced with anticoagulant agents, and the patient was followed up without adverse events. (Level of Difficulty: Advanced.).
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BACKGROUND AND AIM OF THE STUDY: Coronary artery fistula (CAF) is a relatively rare cardiac anomaly. We investigated long-term outcomes following surgical repair of CAF in adults. METHODS: We retrospectively investigated 13 consecutive patients undergoing surgical repair of CAF in our institution between 2008 and 2019 (67.3 ± 10.4 years old, 38% male). CAF types were coronary artery-pulmonary artery fistula (77%), coronary artery-coronary sinus fistula (15%), and both (8%). CAFs originated from the left coronary artery (38%), right coronary artery (8%), and bilateral coronary arteries (38%). Pulmonary and systemic flow (Qp/Qs) was measured in seven patients (54%), with a mean value of 1.52. Seven patients underwent surgery for CAFs alone, and others simultaneously underwent surgery for comorbid cardiac diseases. RESULTS: All procedures were conducted under cardiopulmonary bypass. Surgical procedures were direct epicardial ligation of fistula (92%), direct closure of CAF through pulmonary artery incision (38%), direct closure of CAF through coronary sinus incision (8%), or patch closure of CAF through coronary artery incision (8%). Myocardial perfusion scintigraphy showed asymptomatic myocardial ischemia in the right coronary area after surgery in one patient. There were no deaths perioperatively or during follow-up (mean: 66.6 months). There were no coronary or other CAF-related events. CONCLUSIONS: Several anatomical variations in CAF were observed which coexist with cardiac disease. Long-term outcomes following surgical repair were satisfactory, and the concurrent intervention of CAFs during surgery for comorbid cardiac disease is useful to prevent future complications related CAFs in adults.
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Fístula Arteriovenosa , Anomalias dos Vasos Coronários , Cardiopatias Congênitas , Fístula Vascular , Adulto , Idoso , Angiografia Coronária , Anomalias dos Vasos Coronários/cirurgia , Vasos Coronários/diagnóstico por imagem , Vasos Coronários/cirurgia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do TratamentoRESUMO
Coronary arteriovenous fistulas and coronary cameral fistulas are rare anomalies that involve the abnormal communication between a coronary artery and a venous structure, such as a coronary vein or a right-sided cardiac chamber. Iatrogenic coronary arteriovenous fistulas and coronary cameral fistulas can be uncommon complications of coronary artery angiography and intervention. Acquired coronary arteriovenous fistulas that develop during percutaneous coronary intervention of chronic total occlusions have been previously reported in the literature. However, a coronary arteriovenous fistula resulting from contrast injection into a chronically and totally occluded right coronary artery during diagnostic coronary angiography is very rare. We present a unique case of a contrast-induced iatrogenic right coronary dissection leading to a coronary arteriovenous fistula communicating to the right atrium through the middle cardiac vein.
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Coronary to pulmonary artery fistula is a rare form of congenital coronary artery anomaly. Majority of coronary arteriovenous fistula detected incidentally on coronary angiography. Although, most of these patients are asymptomatic, larger fistulae can produce symptoms of heart failure. Here we present a rare case of 61-year-old female who presented primarily for mitral valve replacement for severe mitral stenosis. On screening angiography, there were two fistula arising from both right and left coronary artery and draining in to the main pulmonary artery. The patient was operated and mitral valve replacement with closure of the fistula. Patient had an uneventful post-operative period and was discharged on 7 the post-operative day.
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BACKGROUND: Current guidelines on coronary anomalies are primarily based on expert consensus and a limited number of trials. A gold standard for diagnosis and a consensus on the treatment strategy in this patient group are lacking, especially for patients with an anomalous origin of a coronary artery from the opposite sinus of Valsalva (ACAOS) with an interarterial course. AIM: To provide evidence-substantiated recommendations for diagnostic work-up, treatment and follow-up of patients with anomalous coronary arteries. METHODS: A clinical care pathway for patients with ACAOS was established by six Dutch centres. Prospectively included patients undergo work-up according to protocol using computed tomography (CT) angiography, ischaemia detection, echocardiography and coronary angiography with intracoronary measurements to assess anatomical and physiological characteristics of the ACAOS. Surgical and functional follow-up results are evaluated by CT angiography, ischaemia detection and a quality-of-life questionnaire. Patient inclusion for the first multicentre study on coronary anomalies in the Netherlands started in 2020 and will continue for at least 3 years with a minimum of 2 years of follow-up. For patients with a right or left coronary artery originating from the pulmonary artery and coronary arteriovenous fistulas a registry is maintained. RESULTS: Primary outcomes are: (cardiac) death, myocardial ischaemia attributable to the ACAOS, re-intervention after surgery and intervention after initially conservative treatment. The influence of work-up examinations on treatment choice is also evaluated. CONCLUSIONS: Structural evidence for the appropriate management of patients with coronary anomalies, especially (interarterial) ACAOS, is lacking. By means of a structured care pathway in a multicentre setting, we aim to provide an evidence-based strategy for the diagnostic evaluation and treatment of this patient group.
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BACKGROUND: An anomalous coronary artery is reported in 2% to 23% of patients with tetralogy of Fallot (TOF). Knowledge of coronary anatomy prior to corrective surgery is vital to avoid damage to vessels crossing the right ventricular outflow tract (RVOT). A meta-analysis on the prevalence of anomalous coronary arteries in TOF is lacking to date. Here, an overview of coronary anomalies in TOF is provided and implications for patient management are discussed. METHODS: PubMed, Embase and Web of Science were searched. Analysis was done using Revman 5.3 (Cochrane Community, London). The primary analysis focused on the origin and proximal course of the right and left coronary arteries. In addition, the prevalence of large conus arteries and coronary arteriovenous fistulas (CAVF) was calculated. RESULTS: Twenty-eight studies, encompassing 6956 patients, were included; 6% of TOF patients have an anomalous coronary artery. Hereof, 72% cross the RVOT; the majority of the remaining 28% courses behind the aorta. Six percent of patients have a large conus artery and 4% a CAVF. Other coronary anomalies include a left or right coronary artery from the pulmonary trunk or left or right pulmonary artery, coronary tree hypoplasia and anastomoses between coronary and bronchial arteries. CONCLUSIONS: The prevalence of coronary anomalies in TOF is 4-6%. In patients with an anomalous coronary artery, 72% cross the RVOT. The combined risk of encountering an anomalous coronary artery or a large conus artery crossing the RVOT is 10.3%. Coronary anatomy should be defined before surgery and the surgical approach adapted accordingly.
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Anomalias dos Vasos Coronários , Tetralogia de Fallot , Anomalias dos Vasos Coronários/diagnóstico por imagem , Anomalias dos Vasos Coronários/epidemiologia , Anomalias dos Vasos Coronários/cirurgia , Ventrículos do Coração , Humanos , Londres , Tetralogia de Fallot/diagnóstico por imagem , Tetralogia de Fallot/epidemiologia , Tetralogia de Fallot/cirurgiaRESUMO
We report a case of surgical treatment of a 58-year-old symptomatic patient with large coronary artery fistula, which drained from the left anterior descending artery into the main pulmonary artery (PA), and concomitant large patent foramen ovale. The surgery was performed through a median sternotomy with aortobicaval total cardiopulmonary bypass. The PA was incised. The fistula was identified 5 mm above the anterior leaflet of the pulmonary valve and was closed off using a prolene suture. Afterward, the atrium septum defect was closed with a Dacron patch via the standard right atrium access. There were no postoperative complications.
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Doença da Artéria Coronariana/cirurgia , Artéria Pulmonar/cirurgia , Fístula Vascular/cirurgia , Procedimentos Cirúrgicos Cardiovasculares , Feminino , Humanos , Pessoa de Meia-Idade , Resultado do TratamentoRESUMO
BACKGROUND: Coronary artery aneurysm (CAA) is defined as dilatation exceeding 1.5 times the width of the normal adjacent coronary artery segments. CAA usually causes few symptoms, and rupture is rare, but can be lethal due to cardiac tamponade when it does occur. CASE PRESENTATION: A 79-year-old woman presented with presyncope and back pain. Emergency surgery was performed based on a diagnosis of cardiac tamponade due to either rupture of coronary arteriovenous fistula or CAA. At surgery, a rupture site was located on the wall of the giant CAA, with a diameter of 55 mm, originating from the ostium of the right coronary artery. Suture closure of the inflow and outflow of the aneurysm was performed, and the aneurysmal cavity was obliterated by multiple sutures. The patient made an uneventful recovery and was discharged from hospital on postoperative day 13. CONCLUSION: On the basis of this case, we propose considering rupture of a CAA as one of the causes of cardiac tamponade.
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We report the use of intraoperative fluorescence imaging to assist in the surgical management of proximal coronary arteriovenous fistulas in four patients.
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Fístula Arteriovenosa/cirurgia , Anomalias dos Vasos Coronários/cirurgia , Fluorescência , Idoso , Fístula Arteriovenosa/diagnóstico por imagem , Corantes , Anomalias dos Vasos Coronários/diagnóstico por imagem , Feminino , Humanos , Verde de Indocianina , Cuidados Intraoperatórios , Pessoa de Meia-IdadeRESUMO
We present an uncommon and underreported complication of coronary artery bypass graft surgery: erroneous anastomosis of the left internal mammary artery to the great cardiac vein. The iatrogenic aorto-coronary arteriovenous fistula with left-to-right shunting resulted in dilation of the coronary sinus, a supporting secondary finding. Factors predisposing to this inadvertent anastomosis include an intramyocardial segment of the left anterior descending coronary artery, demonstrated in this case, as well as epicardial fat and potentially fibrosis of the underlying myocardium.
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Fístula Arteriovenosa/etiologia , Vasos Coronários/cirurgia , Doença Iatrogênica , Anastomose de Artéria Torácica Interna-Coronária/efeitos adversos , Erros Médicos , Idoso , Anastomose Cirúrgica , Fístula Arteriovenosa/diagnóstico por imagem , Fístula Arteriovenosa/fisiopatologia , Fístula Arteriovenosa/terapia , Angiografia por Tomografia Computadorizada , Angiografia Coronária/métodos , Seio Coronário/diagnóstico por imagem , Seio Coronário/fisiopatologia , Vasos Coronários/diagnóstico por imagem , Vasos Coronários/fisiopatologia , Dilatação Patológica , Stents Farmacológicos , Embolização Terapêutica , Humanos , Intervenção Coronária Percutânea/instrumentaçãoRESUMO
A coronary arteriovenous fistula is an abnormal connection between a coronary artery and any of four chambers in the heart. We repot a unique case with a fistulae originating from right coronary artery and draining into the right atrium via coronary sinus although Takotsubo-like left ventricular dysfunction or acute myocardial infarction was initially thought to have occurred according to the electrocardiogram finding.
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Fístula Arteriovenosa/diagnóstico , Aneurisma Coronário/diagnóstico , Anomalias dos Vasos Coronários/diagnóstico , Vasos Coronários , Eletrocardiografia , Cardiomiopatia de Takotsubo/diagnóstico , Função Ventricular Esquerda , Idoso de 80 Anos ou mais , Fístula Arteriovenosa/complicações , Fístula Arteriovenosa/fisiopatologia , Angiografia por Tomografia Computadorizada , Aneurisma Coronário/complicações , Aneurisma Coronário/fisiopatologia , Angiografia Coronária/métodos , Anomalias dos Vasos Coronários/complicações , Anomalias dos Vasos Coronários/fisiopatologia , Vasos Coronários/diagnóstico por imagem , Vasos Coronários/patologia , Diagnóstico Diferencial , Dilatação Patológica , Feminino , Humanos , Tomografia Computadorizada Multidetectores , Valor Preditivo dos Testes , Cardiomiopatia de Takotsubo/fisiopatologiaAssuntos
Angina Pectoris/diagnóstico , Fístula Arteriovenosa/diagnóstico por imagem , Anomalias dos Vasos Coronários/diagnóstico por imagem , Vasos Coronários/diagnóstico por imagem , Artéria Pulmonar/anormalidades , Fístula Arteriovenosa/patologia , Fístula Arteriovenosa/cirurgia , Angiografia Coronária/métodos , Anomalias dos Vasos Coronários/patologia , Anomalias dos Vasos Coronários/cirurgia , Vasos Coronários/patologia , Diagnóstico Diferencial , Feminino , Humanos , Pessoa de Meia-Idade , Artéria Pulmonar/diagnóstico por imagem , Artéria Pulmonar/patologia , Artéria Pulmonar/cirurgia , Doenças Raras , Recidiva , Resultado do TratamentoRESUMO
BACKGROUND: Coronary arteriovenous fistula is a rare congenital or acquired abnormal connection between a coronary artery and any of the great vessels or any of the heart chambers. Most of them are diagnosed during routine coronary angiography. CASE REPORT: This case report illustrates a successful surgical ligating of multiple right coronary artery and circumflex artery fistulas to coronary sinus. CONCLUSION: According to our experience and literature review, it can be concluded that to prevent potential complications in various cases of coronary arteriovenous fistula, early surgical management, just after their condition has been diagnosed, is the best choice.
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BACKGROUND: Coronary arteriovenous fistulas (CAVFs) are direct connections from one or more coronary arteries to cardiac chambers or a large vessel. They are mostly of congenital origin. The aim of this study was to describe clinical presentation and also delineate the course and management of CAVF. METHODS: Clinical data, chest x-rays, echocardiographic and angiographic evaluation of 40 patients with congenital CAVF during 1990 to 2008 were reviewed retrospectively. RESULTS: Seventeen patients were ≤ 20 years old (42.5%) were mostly asymptomatic, and twenty tree cases were older than 20 years old (57.5%), mostly symptomatic (P<0.05). Twenty one (52.5%) patients had pure CAVF and nineteen (47.5%) patients with associated intarcardiac congenital heart disease (15%) or acquired valvular and coronary arteries diseases (32.5%). CAVFs mostly originated from left anterior descending artery (LAD) (42.5%) and mostly drained into the main pulmonary artery (MPA) (35 %). Twenty-four patients underwent CAVF surgical ligation. From twenty-one patients with pure CAVF, eight (38%) patients were complicated by congestive heart failure and aneurism formation of fistula. CONCLUSION: Unlike some previous reports, in our study, the most prevalent origin site for CAVFs was the left anterior descending (LAD). Most patients with CAVFs especially those who went first diagnosed before 20 years old were asymptomatic. On the other hand, as the continuous murmur is not always detected in children or infants, consequently, cases of spontaneous closure may remain undetected. All symptomatic and asymptomatic patients with moderate to severe shunting should be operated on and minimal morbidity and good surgical results could be expected.
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We report the case of a patient with bilateral coronary arteriovenous fistulas (CAVFs) connecting the right coronary artery and left circumflex coronary artery with the right atrium who had progression of first-degree atrioventricular (AV) block to complete AV block during a 4-year period. The His bundle electrogram revealed that the complete AV block was the result of a block at the level of the AV node. Dipyridamole stress thallium-201 myocardial imaging showed decreased perfusion in the inferoapical wall. Coronary angiography and computed tomography showed fistulas that arose from the AV nodal branch of the right coronary artery and from the distal portion of the circumflex coronary artery and drained into the right atrium. Because the fistulas were small, they were not repaired surgically, and a permanent pacemaker was implanted to treat the complete AV block. We presumed that the complication by complete AV block was due to abnormalities of the arteries feeding the AV node and chronic ischemia resulting from a coronary steal associated with the fistulas. To the best of our knowledge, this is the first report of CAVF complicated by complete AV block.
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Coronary arteriovenous fistula (CAVF) is a rare congenital anomaly that is seen in 0.1-0.2% of coronary angiograms. A 79-year-old man with no risk factors for coronary artery disease, presented with unstable angina and normal clinical examination. Coronary angiogram revealed a large left circumflex coronary artery with multiple aneurysms exiting into right atrium. Although coil embolization was feasible, he was managed conservatively as he responded to medications. This case shows that large CAVF can be asymptomatic up to the 7th decade of life, manifest as acute coronary syndrome, can present without any murmur on auscultation, and medical management can be effective.
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PURPOSE: Four pediatric patients with congenital coronary arteriovenous fistula (CAVF) were reported to remind pediatric practitioners and cardiologists of its diagnosis and management. MATERIALS AND METHODS: Four pediatric patients with congenital CAVF from June 1999 to November 2007 were included in this retrospective study. Study modalities included reviews of patients' profiles of clinical features, chest radiograph, Doppler echocardiography, cardiac catheterization with angiography, myocardial perfusion scan, and computed tomography. RESULTS: All 4 patients were symptomatic. The clinical symptoms and signs were feeding problem, continuous murmur, tachycardia, tachypnea, cardiomegaly, and exertional chest pain. Myocardial enzyme was elevated in 1 patient. Echocardiography showed dilatation of the coronary artery in all 4 patients, and traced down its origin in 3 and drainage in 4. The fistulas originated from the right coronary artery in 2 patients and left coronary artery in 2, and were drained into the right ventricle in 2, right atrium in 1, and pulmonary artery in 1. Single left coronary artery was found in 1 patient. The pulmonary-to-systemic blood flow ratios ranged from 1.2 to 2.5. Transcatheter coil occlusion was successfully performed in 4 patients through a coaxial delivery system. The symptoms and signs of congestive heart failure and myocardial ischemia disappeared after the procedure. CONCLUSION: Diagnosis of congenital CAVF could be achieved by appreciation of continuous murmur over area unusual for the ductus, and by scrupulous examination of echocardiography as well as angiography of the coronary artery through which coaxial transcatheter coil occlusion could be performed successfully.