Diagnosis of Coronary Artery Fistulas: Clinical Aspects and Brief Review of the Literature

Abstract

An 86-year-old woman with a history of hypertension, diabetes, coronary artery disease, and arrhythmias was presented to the emergency department with a productive malaise, fever, worsening shortness of breath, and diaphoresis. The patient was normotensive, tachycardic, hypoxic, with regular heart sounds without associated murmur with clinical evidence of congestive heart failure (distension of jugular veins and bilateral basal lung crackles).A 12-lead electrocardiogram revealed sinus tachycardia with a heart rate of 124 beats per minute with new T-wave inversions in lead aVL, and ST depressions in leads V5 and V6. Beta natriuretic peptide was 546 pg/mL. Chest X-ray demonstrated diffuse pulmonary edema.The patient initially was placed on a nitroglycerin drip; however, her blood pressure dropped substantially, and therefore, this medication had to be discontinued. The patient also received nebulizer treatments and oxygen that resulted in improvement of her clinical condition. She was admitted for management of congestive heart failure and pneumonia. She was started on medical treatment of pneumonia (Levofloxacin, Sagent Pharmaceuticals, Schaumburg, IL) and congestive heart failure (furosemide, β-blockers, and angiotensin-converting enzyme inhibitor). Echocardiogram demonstrated multiple wall motion abnormalities, ejection fraction of 30 to 35% with almost global hypokinesis with akinetic areas in the mid septal, basal inferior, and inferoseptal areas, two-fourth diastolic dysfunction, mild mitral regurgitation, and mild pulmonary hypertension. Cardiac catheterization revealed severe triple vessel disease with left dominant system, and aneurysmal left main disease with a critical lesion of proximal circumflex with ulcerated plaque that was subsequently stented. The patient also had a 70% proximal left anterior descending (LAD) lesion and coronary artery to pulmonary artery fistulas originating from the left main coronary artery (►Fig. 1) and right coronary artery (►Fig. 2) with small shunt flow. DiscussionCoronary artery fistula (CAF) is an abnormal communication between a coronary and a heart chamber or any segment of the systemic or pulmonary circulation. These are often grouped together as coronary arterial-venous fistulas. A coronary artery connection to the pulmonary Keywords ► congestive heart failure ► fistulas ► cardiac catheterization ► angiography ► coronary arteries AbstractAn 86-year-old woman with history of hypertension, diabetes, hyperlipidemia, and coronary artery disease was admitted with new-onset congestive heart failure and pneumonia. She underwent coronary angiography after suffering a non-ST elevation myocardial infarction. There was severe coronary artery disease in addition to coronary artery-pulmonary fistulas involving proximal right coronary artery and a branch of left main coronary artery. Coronary artery fistula (CAF) is an abnormal communication between one or more coronary arteries and great vessels or a cardiac chamber. We reviewed 15 cases of CAFs published in PubMed and studied th...

Congenital coronary artery fistulas complicated with pulmonary hypertension: Analysis of 211 cases

“…However, some can be sizeable and lead to shunting of blood from the coronary circulation to low-pressure pulmonary vascular bed, resulting in PHT[1]. …”

“…Most CAFs are small and hemodynamically inconsequential with a negligible shunt. However, some can be sizeable and lead to shunting of blood from the coronary circulation to low-pressure pulmonary vascular bed, resulting in pulmonary hypertension (PHT)[1]. CAFs may be associated with normal[2-4] pulmonary artery pressure (PAP) in unilateral[5-8] or bilateral[9,10] fistulas, or may sometimes be accompanied with elevated PAP[11-14].…”

Recommendations for Multimodality Assessment of Congenital Coronary Anomalies: A Guide from the American Society of Echocardiography

“…The majority of isolated CAFs involves only a single fistula, and the involved coronary bed is more commonly the LCA (39-63%); less often the RCA (29-55%), and least often both (7-19%). [80][81][82][83][84][85] The site of drainage for CAFs is usually a right heart structure; the LV or left atrium are the least common termination sites. CAF termination sites according to CA origin are summarized in Table 3.…”

Coronary artery fistula between single right coronary artery and right pulmonary artery: a case report and literature review

“…CAF is suspected when a continuous murmur with diastolic accentuation at the left sternal edge is heard on a routine clinical examination. Most patients with CAF remain asymptomatic, but elderly patients can present with exertional chest pain and dyspnea, fatigue, congestive heart failure, palpitations, or arrhythmias [ 26 ]. Most fistulas are small and hemodynamically inconsequential.…”

“…Most fistulas are small and hemodynamically inconsequential. However, some can be large and lead to preferential blood flow from coronary circulation to low-pressure pulmonary circulation, resulting in pulmonary hypertension and coronary-steal-related chronic myocardial ischemia [ 26 ]. The prognosis of individuals with an isolated SCA anomaly is uncertain; major adverse cardiac events occur in 15 % before the age of 40 years [ 7 ].…”