Infective Endocarditis Related to a Coronary Artery Fistula with an Unusual Localization and Ectatic Coronary Arteries

Abstract

Coronary artery fistulas (CAF) are a rare cardiac anomaly that can be either congenital or acquired. CAFs have clinical significance because of complications such as dyspnea on exertion, congestive heart failure, and cardiac tamponade. The literature also contains case reports of CAF presenting as bacterial endocarditis. We describe a 31-year-old man who presented with native valve infective endocarditis related to an unusual form of a CAF between the circumflex coronary artery and left ventricle. He also had giant coronary arteries, which were imaged with computed tomography angiography and transesophageal echocardiography. The diameter of the circumflex coronary artery and left main coronary artery was measured as 19 mm. Surgical intervention for heart valves was performed because of vegetations resistant to continued antibiotic treatment. At the same time, the CAF was treated with surgery.

Characteristics of Congenital Coronary Artery Fistulas Complicated with Infective Endocarditis: Analysis of 25 Reported Cases

“…Furthermore, it is assumed that vegetation and perforation occur because of the increased and abnormal turbulent flow (Figure 1 and supporting information video 1) related to fistulas near the cardiac valves. 3,45,47 Additional complications of IE associated with CAFs include septic pulmonary embolism as well as septic embolization to the renal region. 7,14,47,48…”

“…The reason for this is that it is believed that the high‐speed jet lesion may cause damage to the endothelial lining of the myocardium, leading to local vulnerable nidus near the drainage site of the fistula. Furthermore, it is assumed that vegetation and perforation occur because of the increased and abnormal turbulent flow (Figure and supporting information video 1) related to fistulas near the cardiac valves …”

“…Septic emboli to the lungs and the kidney were reported in 6/25 (24%) of the reviewed subjects. 7,13,14,45,47,48 The majority of the septic pulmonary emboli were caused by S. aureus (4/5 5 80%). Dilatation and aneurysm formation of the vessels were present in five of them.…”

“…3,5,15,34,48 , 34 On the other hand, right-sided origin of the fistula with right-sided valve involvement were present in four 3,6,7,45 and fistula with left-sided pathway causing left-sided valve endocarditis were detected in four of the reviewed subjects. 8,10,16,47 It is postulated that jet-related lesions at the site of entry of CAF may cause damage to the intimal wall that may be the site of endocarditis. Furthermore, the turbulent and usually continuous flow related with CAF near the cardiac valves may be responsible for the damage.…”

Coronary Artery Fistula‐Associated Endocarditis: Report of Two Cases and a Review of the Literature

“…TTE only has a sensitivity of 40-63% in detecting valvular vegetation in endocarditis, 28,29 while TEE has a superior sensitivity of 90-100%. [30][31][32] In our two cases here, initial TTE did not identify the CAF; however, the TEE not only clearly identified the vegetation but also accurately diagnosed the CAF here, as well as localizing a vegetation close to the draining site of the CAF. After treating endocarditis with intravenous antibiotics, the patients had a good recovery.…”