Multiple Coronary Chamber Microfistulas or Persistent Thebesian Vessels?

Abstract

Coronary fistulas are rare, not gender-specific congenital conditions, consisting of communications between the coronary arteries and either another coronary vessel or a cardiac chamber. In contrast to large fistulas, small fistulas, named "minimae cordis veneae" or the Thebesius venous system, are draining into heart chambers and form a vascular network in the cardiac lumen. In this article, we present the case of a 72-year-old female with a significant history of cardiovascular disease, admitted to our clinic because of rest dyspnea, fatigue, and minimal chest pain. The 12-lead electrocardiogram showed a trifascicular block (a second-degree atrioventricular block Mobitz II, associated with a right bundle branch block and left anterior fascicle block) and negative T waves in DII, DIII, aVF, V4-V6 leads. An invasive coronary angiography was performed, which revealed no significant atherosclerotic lesions. However, a persistent capillary blush was present at the apex site of the left ventricular chamber, draining from the distal segments of both the anterior descending coronary artery and the posterior interventricular coronary artery. The intramural vascular network generating a left ventricle angiogram image of this kind was suggestive for persistent Thebesian vessels connecting the two coronaries with the left ventricular chamber.

All’s Not Well(ens) that Ends Well: Case Study of Significant Thebesian Veins Mimicking Wellens Syndrome

“…In related case reports, significant coronary artery to LV microfistulae have been observed in patients with and without symptoms of ACS. 1,2,6,8,9 In these published cases, similar EKG changes of T wave inversions in at least one precordial lead as well as ST depressions were imaged. 1,2,6,8,9 Some patients, as with the patient in this case report, presented with elevated troponin levels 2,6 and some were within normal limits 1,8 in spite of their ACS symptoms.…”

“…Importantly, the author's review of cases with obtainable EKGs did show a consistent pattern of T wave inversions in precordial leads, with some EKGs also having negative T waves in inferior leads and/or ST depressions as well. 1,2,5,8 More specifically, a biphasic T wave in V3 appeared unanimously in all patients with extensive thebesian veins, with their EKG showing an appearance consistent for a diagnosis of Wellens Syndrome. 10,11 The author's conclusion is that hemodynamically significant thebesian veins can cause the same ischemic EKG changes similar to those seen in Wellens Syndrome, and that extensive thebesian veins (or microfistulae) should be added and considered as a differential diagnosis when proximal LAD ischemia is suspected from a Wellens Syndrome EKG pattern.…”

“…A coronary artery fistula is an abnormal luminal connection (i.e., communication via a tubular structure) between a coronary artery and either a vein, another artery, or even a ventricular chamber. 1 Thebeisan veins are microfistulous connections between a coronary artery directly to a ventricular or atrial chamber. 2,3 They are important during congenital cardiac circulation, but generally have little contribution to myocardial circulation in adults.…”

Case of Myocardial Infarction with Nonobstructive Coronary Arteries Caused by Thebesian Veins Thrombosis

“…The connection of sinusoids with the branches of the coronary system of the heart is noted. Cernica et al (22) assumed that it may be a compensatory mechanism of myocardial blood supply, especially in ischemic patients. In the current patient, thrombosis of Thebesian veins opening on the endocardium of the left ventricle was noted in the region of myocardial infarction.…”

Prominent Thebesian Veins in Association With Takotsubo Cardiomyopathy

“…EKG findings are typical for T wave inversions in at least one of the precordial leads and associated ST changes [3][4][5][6]. Troponin elevation may be seen in some cases but not all.…”