Coronary artery fistula with myocardial infarction due to steal syndrome

Abstract

Sirs:Coronary artery fistulas are anomalous connections between a coronary artery and a cardiac chamber or great vessel [1]. They are rare abnormalities with a reported incidence of 0.13-0.18% of patients undergoing coronary angiography [2,3]. The majority of coronary artery fistulas are congenital in origin, but they have been reported as acquired complications of chest trauma and surgery also. Most of them are diagnosed incidentally in asymptomatic patients, but depending on shunt volume, congestive heart failure can develop [1]. Furthermore, myocardial ischemia due to a 'steal' from the adjacent myocardium has been reported [4][5][6][7][8][9][10][11][12], but true existence of this phenomenon is a controversial issue [13]. We present the case of a young female with a large coronary artery fistula originating from the proximal left anterior descending artery (LAD), and evidence of a coronary steal syndrome is provided by fractional flow reserve (FFR).A so far healthy 36-year-old female without cardiovascular risk factors presented in our emergency department with sudden onset chest pain following a long exhausting motorbike trip. Physical examination was unremarkable, and no cardiac murmur was audible. Baseline electrocardiogram showed T inversions in the anterior leads, and the cardiac biomarkers were elevated with a peak high sensitive Troponin T of 0.55 lg/l and a peak creatine kinase of 623 U/l. Subsequent left heart catheterization ruled out coronary artery disease, but a large coronary artery fistula originating from the proximal LAD draining into to the pulmonary trunk was found (Fig. 1). Ventriculography showed a hypokinesis of the anterior segments distal to the origin of the fistula, and magnetic resonance tomography revealed a late enhancement pattern of subendocardial myocardial infarction (Fig. 2). Hypothesizing a coronary steal syndrome due to the fistula, a second procedure with left and right heart catheterization was performed. Hemodynamic and oximetric measurements revealed a systemic blood flow (Q S ) of 6.0 l/min and a pulmonary blood flow (Q P ) of 6.7 l/min, leading to a relatively small calculated left-to-right shunt of 0.68 l/min (Q P /Q S = 1.12), and pulmonary artery pressure was in normal range. FFR in the distal LAD was 0.78 under maximal hyperemia, raising to 0.95 while temporary experimental occlusion of the fistula using a 3.0/15 mm standard balloon catheter. In consideration of this evidence of steal syndrome, coil embolization of the fistula was performed in the same procedure, using 2 Detach TM embolization coils (Cook Medical, Bloomington, IN, USA) [2-2 and 2-4 (diameter in mm-length in cm)] in each of the two main branches and another two coils (3-4 and 3-6) in the bifurcation of the fistula (Fig. 1). Finally, a FFR of 1.0 was measured in the distal LAD. The patient was discharged free of symptoms the following day. At 3-month follow-up, the patient was free of symptoms, and echocardiography revealed complete recovery of left ventricular function.A coronary artery fistula is ...

Successful Percutaneous Coil Embolization of a Large and Tortuous Coronary Artery to Pulmonary Artery Fistula

“…In addition, coronary angiography revealed a delayed antegrade coronary flow (TIMI grade 2) in the distal LAD. The majority of coronary artery fistulas are congenital in origin, and most adult patients are asymptomatic (9,15,16). However, it has previously been reported that coronary artery fistulas can cause unstable angina and myocardial infarction in adults (8,9).…”

“…Successful transcatheter closure of a coronary artery fistula was first reported in 1983 (21). Since then, this treatment method has become more popular and is now widely avail- able (6,7,9,(18)(19)(20). Because of the low prevalence of coronary artery fistulas, the optimal management remains unclear and there are no established therapeutic guidelines.…”

“…The majority of coronary artery fistulas are congenital in origin, and most adult patients are asymptomatic (9,15,16). However, it has previously been reported that coronary artery fistulas can cause unstable angina and myocardial infarction in adults (8,9). We did not perform stress myocardial perfusion scintigraphy or other stress testing to evaluate myocardial ischemia caused by the fistula due to the risk of inducing severe myo-cardial ischemia.…”

“…In this case, we successfully performed percutaneous coil embolization even though the fistula was large and tortuous. Recent improvements in endovascular techniques and devices have resulted in the increased use of percutaneous intervention for the noninvasive treatment of coronary artery fistulas (6,7,9,(18)(19)(20).…”

“…Coronary artery fistulas can result in heart failure (4-7), myocardial ischemia (4,6,(8)(9)(10), endocarditis (11) and rupture of aneurysmal vessels (12)(13)(14). The majority of coronary artery fistulas originate from the right coronary artery or left anterior descending artery (LAD) and connect with a pulmonary artery, pulmonary vein, cardiac chamber, coronary sinus or the vena cava (15)(16)(17).…”