Left Main Coronary Artery Aneurysm with Fistula to Superior Vena Cava: A Challenging Case

Coronary artery fistulas (CAFs) are rare congenital coronary artery abnormalities, with direct communication between a coronary artery and a cardiac chamber, great vessel or other structure. We report here, a rare case of a 25?year?old male with CAF from the aneurysmal left main coronary artery to the superior vena cava detected on echocardiography and computerized tomography (CT) coronary angiography

Resisting Arrest: Perioperative Confirmation and Management of an Iatrogenic Aortocoronary Arteriovenous Fistula after Coronary Artery Bypass Grafting for Redo Cardiac Surgery

Although rare, iatrogenic aortocoronary arteriovenous fistulae (ACAVF) occur when a coronary graft is mistakenly anastomosed to an epicardial vein rather than its intended arterial target. Patients may be asymptomatic, demonstrate angina, dyspnea, arrhythmias, syncope, or diminished exercise capacity, and may have wide pulse pressures with evidence of coronary steal. A thorough insight into the disordered anatomy is critical to safely manage a patient for redo cardiac surgery, especially when attempting to arrest the heart. We present a case for redo cardiac surgery of an iatrogenic ACAVF confirmed perioperatively with multiple modalities and its intraoperative management.

Vieussens' ring fistula to pulmonary artery: embolization with grandmother-mother-child technique / Fístula del anillo de Vieussens a arteria pulmonar: embolización con técnica abuela-madre-hijo

Abstract A 53-year-old man with an asymptomatic fistula from the Vieussens ring to the pulmonary artery presented with progressive respiratory distress. Coil embolization of this type of fistula has been described by femoral access. The advanced transradial "grandmother-mother-son" technique for high active support safely allows successful embolization of this type of coronary fistulae.

Resumen Un hombre de 53 años con una fístula asintomática del anillo de Vieussens a la arteria pulmonar comenzó con dificultad respiratoria progresiva. La embolización con coils de este tipo de fístulas ha sido descrita por acceso femoral. La técnica transradial avanzada "abuela-madre-hijo" para un alto soporte activo permite de manera segura la embolización exitosa de este tipo fístulas coronarias.

Clinical analysis of congenital coronary artery fistula in 71 children / 中华实用儿科临床杂志

Objective:To explore the clinical characteristics, therapeutic efficacy and prognosis of congenital coronary artery fistula (CAF) in children.Methods:Clinical data of 71 pediatric patients diagnosed with congenital CAF at Department of Cardiology and Department of Cardiac Surgery, Shanghai Children′s Medical Center, Shanghai Jiao Tong University School of Medicine from January 2013 to June 2019 were retrospectively analyzed.The median age was 2.2 years (0.1-14.0 years), and the median body weight was 18.3 kg (3.2-55.8 kg), including 37 males (52.1%) and 34 females (47.9%). They were divided into the transcatheter closure group (30 cases) and surgical repair group (41 cases). The therapeutic effect and follow-up data of the 2 groups were compared by the Fisher′ s exact test. Results:Among the 71 congenital CAF children, 70 had heart murmurs, 2 had chest tightness after activity, and 5 were prone to recurrent respiratory tract infection.Transcatheter closure and surgical repair were successfully performed in 22/30 (73.3%) and 41/41 (100.0%) cases with a statistically significant difference ( P=0.001). However, in the surgical repair group, 1 (2.4%) case died after operation and 2(4.9%) needed further transcatheter closure due to large residual shunt during the follow-up period.At the last follow-up, there were 2 cases with minimal or small residual shunt in both groups ( P=0.567). There were 2/71(2.8%) cases suffering from postoperative thrombosis. Conclusions:Cardiac murmur is the main sign of congenital CAF in children, and some of them may have frequent respiratory tract infection due to increased lung blood caused by a large amount of shunt.A few children have chest tightness and chest pain due to myocardial ischemia caused by coronary steal.Both percutaneous closure and surgical repair are safe and effective with few complications.

A study of simple congenital coronary artery anomalies based on a large-sample coronary CT angiography / 中华放射学杂志

Objective:To investigate the classification and prevalence of simple congenital coronary artery anomalies (CCAA) in Chinese in a large samples of coronary CT angiography (CCTA), and briefly summarize the CT characteristics of "malignant" anomalies.Methods:The data of patients who had undergone CCTA from July 2009 to January 2017 and were diagnosed as simple CCAA were analyzed retrospectively. CCAA were classified according to the origination, number of orifices and termination, and the prevalence of various CCAA was statistically analyzed. Anomalous origin of coronary artery included the origin of coronary artery from the opposite coronary sinus, the non-coronary sinus, the aorta or around the primary sinus, the pulmonary artery, and left circumflex artery originated from the diagonal branch. Abnormal number of orifices included single coronary artery (SCA), right coronary artery and conus branch arising separately, and left anterior descending branch and circumflex branch arising separately. Abnormal termination was coronary artery fistula (CAF). Anomalous origin of coronary artery from the opposite sinus, anomalous origin of the coronary artery from the pulmonary artery, SCA, and multiple or large CAFs were defined as"malignant"anomalies.Results:Among 165 133 patients, 2 148(1.301%) had coronary anomalies, including 1 302 (0.789%) of origin anomalies, 298 (0.181%) of abnormal number of orifices and 548 (0.332%) of abnormal termination. There were 700 cases (0.424%) with coronary artery rising from the opposite sinus, 179 of which had opening or proximal lumen stenosis due to compression, 7 of which had subendocardial myocardial ischemia or infarction on CCTA without coronary artery disease (CAD). The coronary arteries originated from posterior sinus, the aorta or around the primary sinus were found in 48 cases (0.029%), 531 cases(0.322%), respectively. Coronary artery originating from pulmonary artery was detected in 20 cases (0.012%), all of which were left main trunk originating from pulmonary artery, showed tortuous dilation of coronary arteries. Five cases showed obvious subendocardial myocardial ischemia or infarction without CAD. SCA, right coronary artery and conus branch arising separately, left anterior descending branch and circumflex artery arising separately were detected in 102 (0.062%), 53 (0.032%) and 143 (0.087%) cases respectively. Only 1 of 102 cases with SCA showed myocardial ischemia without CAD. A total of 548 cases (0.332%) were diagnosed as CAF, of which the coronary-pulmonary fistula was most common with a highest prevalence of 0.277% (458 cases). Coronary artery-atrial fistula and coronary artery-ventricular fistula were detected in 22 (0.013%) and 60 (0.036%) cases. There were 6 cases (0.004%) of coronary artery-coronary venous fistula and 2 cases (0.001%) of coronary artery-superior vena cava fistula.Conclusions:The occurrence of CCAA is not uncommon, among which anomalous origin of coronary artery is the most common, and special attention should be paid to "malignant"anomalies.

Fístula coronaria a ventrículo derecho en paciente con ateroesclerosis sistémica / Coronary artery fistula to the right ventricle in a patient with systemic atherosclerosis

RESUMEN La ateroesclerosis es una enfermedad sistémica que afecta múltiples lechos vasculares. Después de períodos prolongados de progresión comienzan las manifestaciones clínicas, de forma aguda o crónica (infarto agudo de miocardio, angina estable, claudicación intermitente, enfermedad cerebrovascular, entre otras); por lo que puede cursar de manera subclínica en pacientes con enfermedad arterial coronaria. Lo interesante de esta forma de presentación es que dentro de una serie de casos con enfermedad multivaso, asociado a un índice tobillo-brazo (ITB) < 0,9, después de un síndrome coronario agudo, hemos encontrado, como hallazgo angiográfico, la presencia de una fístula coronaria a ventrículo derecho en un paciente con ITB muy bajo y clínica de claudicación intermitente. Esta fístula es la causa de los síntomas que interrumpieron la rehabilitación cardiovascular; es una enfermedad poco frecuente y causa de dolor torácico, que se informa solo de 0,3 a 0,8%, como hallazgo incidental en angiografías coronarias.

ABSTRACT Atherosclerosis is a systemic disease that affects a number of vascular beds. Clinical manifestations whether acute or chronic (acute myocardial infarction, stable angina, intermittent claudication, cerebrovascular disease, among others) start after long periods of progression; so it may present subclinically in patients with coronary artery disease. What is particularly interesting about this form of presentation is that within a series of cases with multivessel disease, associated with an ankle-brachial index (ABI)<0.9, after an acute coronary syndrome, we have identified, as an angiographic finding, the presence of a coronary artery fistula to the right ventricle in a patient with very low ABI and clinical intermittent claudication. This fistula led to the symptoms that hampered cardiovascular rehabilitation. It is an infrequent disease characterized by chest pain; with low reporting (0.3 to 0.8%), as an incidental finding in coronary angiographies.

Fístulas coronario-pulmonares asintomáticas. Reporte caso / Asymptomatic coronary-pulmonary fistulas. Case report / Fístulas coronário-pulmonares assintomáticaso. Relato de caso

Resumen: La fístula coronaria es una anomalía caracterizada por una comunicación anormal entre una arteria coronaria y una cámara cardíaca o un gran vaso. El 50% de las fístulas se originan de la arteria coronaria derecha, 45% de la arteria coronaria izquierda y menos del 5% en ambas. Se presenta una paciente femenina de 81 años de edad con historia de ataque cerebrovascular isquémico de forma previa, quien ingresa con nuevo evento isquémico cerebral. En estudios complementarios se documentó una fracción de eyección del ventrículo izquierdo reducida por lo que se realizó arteriografía con hallazgo de arterias coronarias epicárdicas sin enfermedad obstructiva significativa, pero con fístula coronario-pulmonar en segmento medio de arteria descendente anterior y una fístula coronario-pulmonar en segmento proximal de la arteria coronaria derecha. Las fístulas coronarias son una entidad rara, con síntomas inespecíficos. La mayoría de las veces se diagnostica de forma incidental al realizar una arteriografía coronaria por otro motivo. El manejo varía de acuerdo a las manifestaciones y anatomía encontrada junto con la experiencia del equipo de cardiología.

Abstract: Coronary fistula is an abnormality characterized by abnormal communication between a coronary artery and a cardiac chamber or large vessel. Half of fistulas originate from the right coronary artery, 45% from the left coronary artery, and less than 5% originate from both. We present an 81-year-old female patient with a history of previous ischemic stroke, who was admitted with a new cerebral ischemic event. In complementary studies, a reduced ejection fraction of the left ventricle was documented, then arteriography was performed showing epicardial coronary arteries without significant obstructive disease, but with coronary-pulmonary fistula in the middle segment of the anterior descending artery and a coronary-pulmonary fistula in the proximal segment of the right coronary artery. Coronary fistulas are a rare entity, with nonspecific symptoms. Most of the time this entity is diagnosed incidentally when performing a coronary arteriography for another reason. Management varies according to the manifestations and anatomy found along with the experience of the cardiology team.

Resumo: A fístula coronária é uma anormalidade caracterizada pela comunicação anormal entre uma artéria coronária e uma câmara cardíaca ou um vaso grande. Metade das fístulas são originárias da artéria coronária direita, 45% da artéria coronária esquerda e menos de 5% são originárias de ambas. Se você apresentar um paciente feminino de 81 anos de idade com história de ataque cerebrovascular isquêmico de forma prévia, que ingressou com o novo evento isquêmico cerebral. Em estudos complementares, documentou-se uma fração de ejeção reduzida do ventrículo esquerdo e, em seguida, foi realizada arteriografia mostrando artérias coronárias epicárdicas sem doença obstrutiva, mas com uma fístula coronário-pulmonar no segmento médio da artéria descendente anterior e uma fístula coronário-pulmonar no segmento proximal da artéria artéria coronária direita. As fístulas coronárias são uma entidade rara, com sintomas inespecíficos. Na maioria das vezes, essa entidade é diagnosticada incidentalmente ao realizar uma arteriografia coronariana por outro motivo. O manejo varia de acordo com as manifestações e anatomia encontradas, juntamente com a experiência da equipe de cardiologia.

Autologous Pericardial Patch Closure for a Giant Right Coronary Artery Aneurysm with a Coronary Arteriovenous Fistula / 日本心臓血管外科学会雑誌

A 53-year old female was noted to have an enlarged heart on a medical checkup. A multislice computed tomography study demonstrated a giant coronary artery aneurysm measuring 10 cm in diameter and a coronary arteriovenous fistula, both located below the left atrium. Resection of the aneurysm and ligation of the feeding arteries and arteriovenous fistula were performed under cardiopulmonary bypass. As the native coronary sinus was occluded, we reconstructed the vessels draining from the aneurysm into the right atrium with an autologous pericardial patch to preserve the coronary venous blood flow. To our knowledge this is the first report of an autologous pericardial patch being successfully used to reconstruct the coronary venous flow during surgical treatment of a giant coronary artery aneurysm with a coronary arteriovenous fistula.

Double Coronary Artery Fistula from Left Circumflex Artery draining to the left Atrium in a Rheumatic Heart Disease patient – A case report

Introduction@#Coronary artery fistula (CAF) is a connection between one or more of the coronary arteries and a cardiac chamber or great vessel. This is a rare defect and occurs in only 0.2% of the population. Most of the cases are congenital but acquired causes are also reported. A CAF may occur as an isolated cardiac defect or with other cardiac diseases such as rheumatic heart disease (RHD). Only a few cases of coexisting CAF and RHD have been reported. Local data reports only 0.69% CAFs associated with congenital malformations of the heart. Only 61 patients among all patients who underwent coronary arteriography in 34 years were reported to have a CAFs. We report a case of severe mitral stenosis (MS) with a double CAF from the left circumflex (LCx) artery draining into the left atrium. @*Case@#A 46-year old female with RHD with severe MS came in due to progressive dyspnea. The coronary angiogram revealed two fistulous tracts originating from the LCx draining into the left atrium. She underwent mitral valve replacement (MVR) surgery, left atrial plication, and closure of the fistula drainage the left atrium. The postoperative course was uneventful. @*Discussion@#A CAF is often asymptomatic until the second decade of life. Untreated, this may progress and cause ischemic and heart failure signs and symptoms. The presence of MS caused elevated left atrial pressure which might have prevented the increase in the volume of blood draining from the LCx artery to the left atrium through the fistulas. Hence, the MS might have prevented the dilatation of the two fistulas. Surgical correction is also indicated in the fistulas since resolution of the mitral stenosis with MVR will decrease the LA pressure which might result to dilatation and increased drainage of the fistulas causing complications later.

The application value of virtual reality technology in the surgical treatment of coronary artery fistula and abnormal origin of coronary artery / 中国胸心血管外科临床杂志

@#Objective To evaluate the application value of virtual reality (VR) technology in the surgical treatment of coronary artery fistula (CAF) and abnormal origin of coronary artery (AOOCA). Methods From January 2014 to June 2018, with the assistance of virtual reality technology, 4 patients with CAF and 4 patients with AOOCA in the Department of Cardiac Surgery of our hospital underwent treatment method deciding and operation details planning. In the CAF patients, there was 1 male and 3 females and they were 8 years, 16 years, 62 years, and 65 years, respectively. In the AOOCA patients, there was 1 male and 3 females at age of 4-month, 2 years, 14 years, and 29 years, respectively. Results The virtual heart models in all 8 patients were well matched with the real heart. The spatial structure information of CAF/AOOCA and surroundings can be intuitively and fully shown by virtual reality technology in all patients. All of the 4 CAF patients repaired coronary artery incision, including 2 patients with autologous pericardium patch and 2 patients with direct suture. Of the 4 AOOCA patients, 3 underwent coronary directly transplantation but 1 underwent Takeuchi surgery. And 2 had mitral valve plasty at the same time. All the operations were completed successfully, with good recovery and no serious complications. Among the 4 CAF patients, 3 had no residual fistula, and 1 had minor residual fistula. Coronary arteries were all unobstructed in 4 patients of AOOCA; moderate and severe mitral regurgitation in 2 patients were significantly reduced after surgery. Conclusion VR allows doctors to understand the spatial structure information of CAF/AOOCA and surroundings before the operation, and assists them to make accurate treatment decisions and develop detailed surgical plans before the operation, ensuring its safety. Its clinical application value is significant.

The value of fetal echocardiography in the diagnosis of isolated coronary artery fistula / 中华超声影像学杂志

Objective@#To investigate the ultrasonic features of fetal isolated coronary artery fistula (CAF).@*Methods@#A total of 13 cases of fetal isolated CAF from December 2011 to March 2018 were retrospectively analyzed. Data of echocardiography and follow-up were collected.All cases were divided into retrograde group and no retrograde group based on the presence of diastolic retrograde flow in aortic arch. The inner diameters of affected coronary arteries (CA) and aortic annulus (AO) were measured, and the CA to AO ratios (CA/AO) were then calculated.Correlations between CA, CA/AO and the presence of retrograde flow were analyzed. Adverse birth outcomes including abortion, enlarged cardiac cavity, pulmonary hypertension were recorded at follow-up. Correlation between diastolic retrograde flow in aortic arch and the rate of adverse birth outcomes was analyzed.@*Results@#①Thirteen cases of fetal CAF were characterized by the varying degrees of dilation of affected coronary arteries. Thirteen cases were presented with abnormal blood flow in the large arteries or cardiac cavities: biphasic continuous flow pattern in atrio-coronary fistula and biphasic bidirectional continuous flow pattern with a diastolic dominant flow in coronary artery to ventricle fistula. Seven cases were presented with retrograde holodiastolic flow in aortic arch. ②The CA/AO ratios of retrograde group was higher than in no retrograde group [(0.63±0.24)mm vs (0.39±0.09)mm, P=0.047], there was no significant difference of CA between the two groups [(3.00±1.25)mm vs (2.03±0.62)mm, P=0.115]. ③The rate of adverse birth outcomes in retrograde group was higher than in no retrograde group (80% vs 20%, χ2=4.80, P=0.028).@*Conclusions@#Fetal isolated CAF has distinct ultrasonic features. Abnormal CA/AO ratio and diastolic retrograde flow in aortic arch are significant ultrasonic features and has prognostic values.

The value of fetal echocardiography in the diagnosis of isolated coronary artery fistula / 中华超声影像学杂志

Objective To investigate the ultrasonic features of fetal isolated coronary artery fistula ( CAF) . Methods A total of 13 cases of fetal isolated CAF from December 2011 to M arch 2018 were retrospectively analyzed . Data of echocardiography and follow‐up were collected .All cases were divided into retrograde group and no retrograde group based on the presence of diastolic retrograde flow in aortic arch . T he inner diameters of affected coronary arteries ( CA ) and aortic annulus ( AO ) were measured ,and the CA to AO ratios ( CA/AO ) were then calculated .Correlations between CA ,CA/AO and the presence of retrograde flow were analyzed . Adverse birth outcomes including abortion , enlarged cardiac cavity , pulmonary hypertension were recorded at follow‐up . Correlation between diastolic retrograde flow in aortic arch and the rate of adverse birth outcomes was analyzed . Results ① T hirteen cases of fetal CAF were characterized by the varying degrees of dilation of affected coronary arteries . T hirteen cases were presented with abnormal blood flow in the large arteries or cardiac cavities :biphasic continuous flow pattern in atrio‐ coronary fistula and biphasic bidirectional continuous flow pattern with a diastolic dominant flow in coronary artery to ventricle fistula . Seven cases were presented with retrograde holodiastolic flow in aortic arch . ②T he CA/AO ratios of retrograde group was higher than in no retrograde group [ ( 0 .63 ± 0 .24 ) mm vs ( 0 .39 ± 0 .09) mm , P ＝0 .047] ,there was no significant difference of CA between the two groups [ ( 3 .00 ± 1 .25) mm vs ( 2 .03 ± 0 .62) mm , P ＝0 .115] . ③T he rate of adverse birth outcomes in retrograde group was higher than in no retrograde group ( 80% vs 20% ,χ2 ＝4 .80 , P ＝0 .028) . Conclusions Fetal isolated CAF has distinct ultrasonic features . Abnormal CA/AO ratio and diastolic retrograde flow in aortic arch are significant ultrasonic features and has prognostic values .

Treatment and follow-up of congenital coronary artery fistula with giant coronary artery aneurysm in children / 中华实用儿科临床杂志

Objective To analyze the treatment and follow-up of congenital coronary artery fistula (CAF) with giant coronary artery aneurysm (GCAA) in children.Methods The clinical data were analyzed retrospectively in 13 patients who were diagnosed as congenital CAF with GCAA between July 2009 and December 2016 in Guangzhou Women and Children's Medical Center.There were 8 boys and 5 girls.The median age was 18 months,ranging from 40 days to 12 years old.The body weight ranged from 3.8 kg to 29.0 kg with a median of 8.8 kg.Fistulas originated from right coronary artery accounted in 8 patients,with 5 from left coronary artery.Fistulas drained into right atrium in 3 patients,right ventricular in 8 patients and left ventricular in 2 patients.Single fistula occurred in 12 patients and multiple fistulas in 1 patient.The diameter of coronary artery aneurysm ranged from 8 mm to 16 mm with a median of 9.2 mm.Results One patient had tachypnea and growth retardation without heart murmur.The other 12 patients were asymptomatic with heart murmurs occasionally found in routine physical examination.One patient underwent fistula ligation without cardiopulmonary bypass (CPB).The remaining 12 cases received fistula correction with beating heart CPB.Direct suture was used in 10 patients and autologous pericardial patch in other 2 patients.Two patients were associated with atrial septal defect (ASD) and underwent repair of ASD concurrently.The coronary artery aneurysm remained original shape without any intervention during the operation.The mean hospital delay was (11.0 ± 2.5) days.Two patients had decreased ejection fraction as low as 38％ within 3 days after the operation,but went up to over 50％ in follow-up 1 month later.Transient T wave change occurred in 7 patients,and another 2 patients showed a residual shunt with size of 1 to 2 millimeters through the fistula without further intervention after the surgical closure.All 13 patients had antiplatelet therapy with 12 taking Aspirin and one taking Dipyridamole.The dosage was 3-5 mg/(kg · d) with duration ranging from 3 days to 13 months with a median of 1 month.During the perioperative period and the follow-up period (3 months to 8 years),all patients were asymptomatically alive.Transthoracic echocardiography showed normal cardiac function.Compared with preoperative status,the diameter of dilated coronary arteries was not changed after the operation.There was no formation of thrombus in the coronary arteries.Electrocardiography showed no ST-T changes or arrhythmia or myocardial ischemia.Conclusions GCAA can be combined with congenital CAF in children,so it needs early operation.The evidence-based intervention of coronary artery aneurysm and usage of anticoagulant and antiplatelet therapy in pediatric patients was still lacking,which needs long-term follow-up.

The surgical outcome and follow-up of congenital coronary artery fistula in children / 中华胸心血管外科杂志

Objective Analyze the surgical and follow-up outcomes of congenital coronary artery fistula(CAF) in children and to discuss the treatment methods.Methods The clinical data were analyzed retrospectively in 22 patients who were diagnosed as congenital CAF and received surgical treatment between July 2008 and January 2017 in Guangzhou Women and Children's Medical Center.There were 14 boys and 8 girls.The median age was 17 months ranging from 14 days to 12 years old.The median weight was 8.8 kilograms ranging from 3.0 to 31.0 kilograms.Results Two patients had shortness of breath.Three had growth retardation with recurrent respiratory infection or tachypnea.The remaining 17 patients were asymptomatic.Twenty had heart murmurs.Fistulas originated from right coronary artery accounted for 11 patients,with 10 from left coronary artery,1 from both right and left coronary arteries.Fistulas drained into coronary sinus in 1 patient,right atrium in 6 patients,right ventricular in 13 patients and left ventricular in 2 patients.Single fistula occurred in 20 patients and multiple fistulas in 2 patients.The coronary arteries were obviously dilated in all patients with diameter from 4.0 to 12.0 millimeters.There were 8 cases with aneurysmal dilation of coronary arteries.Two patients underwent fistula ligation without cardiopulmonary bypass(CPB).The remaining 20 cases received fistula correction with beating heart CPB.Direct suture was used in 3 patients for closure of fistula inlet and 11 children for outlet.Both inlet and outlet were closed in 6 patients,and in 2 of them autologous pericardial patch was used for outlet.Other associated intra-cardiac anomalies in 7 children were corrected during the operation.The aneurysmal coronary arteries remained original shape without any intervention during the operation.The mean hospital delay was(12.3±3.2) days.Two patients appeared decreased heart function within 3 days after the operation,and recovered in return visit one month later.Another 2 patients showed a residual shunt with size of 1 to 2 millimeters through the fistula without further intervention after the surgical closure.During the perioperative period and the follow-up period(3 months to 8 years),all 22 patients were asymptomatically alive without regular anticoagulation management.Transthoracic echocardiography showed normal cardiac function.Compared with preoperative status,the diameter of dilated coronary arteries was reduced over 6 months follow up after the operation.There were no formation of thrombus in the coronary arteries.Electrocardiography showed no ST-T changes or arrhythmia or myocardial ischemia.Conclusion Clinical symptoms can be appeared in children with congenital CAF due to large shunt.Surgical correction is an effective method for the management of single CAF or CAF with coexisted intra-cardiac anomalies.The outcome was well.

Congenital coronary artery anomaly in an adult: Double Barrel Left Coronary System and Coronary Artery Fistula Connecting a giant left circumflex artery to the coronary sinus

Introduction@#Coronary anomalies are rare congenital anatomic patterns affecting approximately one percent of the general population. Most of the cases may be asymptomatic and are never detected. Rarely, they result in severe life threatening consequences, thus, the diagnostic challenge is recognizing the abnormality early. Cardiac imaging modalities such as echocardiography, coronary computed tomography angiography (CTA), and coronary angiography can help us in the diagnosis.@*Case@#A 49-year-old female who initially presented with dyspnea and managed as rheumatic heart disease and hypertension. An echocardiogram finding prompted further investigation with coronary CTA and coronary angiography which identified the coronary artery anomalies. She was advised surgery but was unable to comply. Accordingly, medical management of her heart failure symptoms was pursued. She eventually succumbed to multiorgan failure as the complications of the fistula set in, three years after she had her initial presentation.@*Discussion@#The normal coronary anatomy consists of the the right and left coronary arteries that originate from the aorta. Our patient has two coronary artery anomalies: one is the double barrel left coronary system - her left anterior descending artery and left circumflex artery (LCX) originate directly from the aorta instead of from the left coronary artery. Second, is the coronary artery fistula (CAF), with her LCX draining into the right atrium through the coronary sinus. CAFs tend to grow with age, and if untreated, can cause clinical symptoms in older patients. The consequences of the patient’s abnormal connection may have caused volume overload to the right sided chambers resulting to heart failure. In adults with a congenital heart disease such as the CAF, it is recommended that if a continuous murmur is present, it should be defined either by echocardiography, magnetic resonance imaging, CTA, or cardiac catheterization.@*Conclusion@#A high level of suspicion for a CAF as a cause of an adult patient’s progressive heart failure can lead to timely diagnosis and optimal interventions.

Value of 256-slice CTA for evaluation of coronary artery fistula / 实用放射学杂志

Objective To investigate the clinical value of 256-slice CT angiography (CTA) in diagnosing coronary artery fistula(CAF).Methods A total of 18 patients with CAF were analyzed retrospectively.The raw data were transferred to the work station.Image reconstruction techniques were employed, including multiplanar reconstruction (MPR),curved planar reconstruction (CPR),maximum intensity projection (MIP) and volume render (VR).Results Coronary artery angiography showed fistula affluxed to the pulmonary artery in 5 cases,affluxed to the coronary sinus in 5 cases,affluxed to the right atrium in 3 cases,affluxed to the left atrium in 3 cases, affluxed to the right ventricle in 2 cases.The blood flow from abnormal vessels to pulmonary arteries was demonstrated in 5 patients,and injection sign or hyper-density of contrast material in the main pulmonary artery was seen.The tortuous vascular networks on the surface of the main pulmonary artery trunk were seen in 2 cases.Formation of aneurysm was seen in 3 cases.Conclusion 256-slice CTA can precisely show the detailed anatomy variations and heomodynamic information of CAF, and directly display the abnormal vessels with multiple image reconstruction techniques.

Application of Amplatzer vascular Plug Ⅱ in pediatric coronary artery fistula patients treated with transcat-heter closure / 中华实用儿科临床杂志

Objective To investigate the feasibility and safety of transcatheter closure of coronary artery fistula (CAF)with Amplatzer vascular PlugⅡ(AVPⅡ)in pediatric patients.Methods Between June 2012 and October 2015,5 children aged 0.9 to 7.0 years old and weighted 10 to 21 kg with CAF were admitted to the Department of Pediatric Cardiology in Shandong Provincial Hospital Affiliated to Shandong University.Aortic root angiography was used first to confirm the origin,shape,branches,drainage and the diameter of the orifice of CAF by deploying the pigtail catheter.The AVPⅡwas retrogradely deployed into targeted artery through guiding catheter and aortic angiography was performed before releasing the plug.Results All the 5 children underwent transcatheter closure by AVPⅡsuccessful-ly.Two cases were involved with right coronary -right ventricular fistula,1 case of left anterior descending coronary -right ventricular fistula (residual fistula after surgical repair),and 1 case of left circumflex coronary -left atrial fistula. Four children had a single fistula,and 1 case had double fistulas.The diameter of the orifice ranged from 2.00 to 5.96 mm,and the selected occluders from 8 to 14 mm.The ratio of diameter of occluder to fistula orifice ranged from 2.3 to 3.4.All the patients were followed up for 4 to 44 months.Two patients developed instant minor and modera-te aortic re-gurgitation.No other complications such as thrombosis,embolization,residual shunt,arrhythmia,coronary dissection or perforation occurred.Conclusions Transcatheter closure of CAF by AVPⅡin pediatric patients is feasible and safe. Aortic regurgitation should be noted,especially during the procedure.

Efficacy analysis of transcatheter closure of coronary artery fistulas in 70 cases: A single center experience / 第二军医大学学报

Objective To evaluate the efficacy of percutaneous intervention closure of coronary artery fistula(CAF) and summarize our single-center experience. Methods We retrospectively analyzed the clinical data of 70 patients who successfully underwent transcatheter closure of CAF from August 2009 to August 2015 in our department. Results There were a total of 101 fistulas in the 70 patients (female 40%, average age[56.30±15.54] years, ranged from 15-83 years). And it was found that 8.91% of the CAFs were originated from the left main artery, 42.57% from the left anterior descending coronary artery, 14.85% from the left circumflex coronary artery, and 33.67% from the right coronary artery. The drainage sites included the pulmonary artery (78.22%), the right atrium(15.84%), the right ventricle(1.98%), and others (3.96%). The mean diameter of fistulas was (3.95±2.61) mm. All the 70 patients underwent transcatheter closure successfully, and the devices included coils (85.71%, mean number of coils were[2.55±1.76]), patent ductus arteriosus closures (7.14%), plug (2.86%), muscular ventricular septal defect occluders (2.86%) and covered stent (1.43%).The mean size of occluders was (13.33±4.32) mm. The patients received aspirin (3-5 mg/kg) every day for 6 months postoperatively. Follow-up ranged from 1 to 73 months (average[33.94±20.93]months), and no patient showed hemorrhage, hemolysis, thrombosis, chest pain or other complications. Conclusion Transcatheter closure of CAF is safe and efficient, with less trauma, and it is therefore worth popularizing in clinic.

Complex Coronary Artery Fistula Causing Angina is Resolved Through Coil Embolization

Coronary artery fistulas (CAFs) are rare, mostly congenital cardiac anomalies. Most are asymptomatic and do not require treatment, but some can cause angina or exertional dyspnea. Symptomatic or hemodynamically significant fistulae can be treated with transcatheter or surgical methods of closure, with the former being a less invasive alternative while showing similar effectiveness and morbidity. We present a 52-year-old man with a complex coronary artery to pulmonary artery fistula causing angina, successfully treated by transcatheter coil embolization. Even without complete closure, this patient showed improvement of symptoms and objective indices of myocardial ischemia.

Interventional treatment of coronary artery fistulas by using Guglielmi detachable coils：analysis of feasibility and safety with single center experience / 介入放射学杂志

Objective To summarize the experience in treating coronary artery fistula (CAF) by using Guglielmi detachable coils. Methods During the period from July 2009 to November 2014 at the Affiliated Changhai Hospital of Second Military Medical University, interventional treatment of CAF by using Guglielmi detachable coils was performed in 40 patients. The clinical data were retrospectively analyzed. The feasibility, safety and effectiveness of this technique were evaluated. Results Successful transcatheter closure of CAF with Guglielmi detachable coils was achieved in all 40 patients; the average Guglielmi detachable coils used in each patient was(2.33±1.38) coils. No procedure-related complications occurred. Intra-operative angiography showed that residual shunt completely disappeared in 12 patients (30%) and blood flow was significantly decreased in 28 patients (70%). All the patients were followed up for 1-65 months, neither complications such as recurrent bleeding and ischemia nor stenosis and occlusion of related arteries, or fistula cavity rupture occurred. Conclusion The use of Guglielmi detachable coil in interventional treatment of CAF is safe and effective, although its long-term effect needs to be further verified.