Surgical treatment of heart failure due to giant coronary artery fistula: a case report

Abstract

Coronary artery fistula is a rare congenital cardiac anomaly that is often found incidentally during computed tomography angiography. Coronary fistula between the left circumflex coronary artery and the coronary sinus is among the less common forms of coronary artery fistula. A 60-yea\r-old female patient presented to our outpatient cardiology department with symptoms of severe, de novo heart failure. Echocardiogram revealed severe mitral regurgitation and a dilated duct that turbulently accelerated colour Doppler flow behind the left ventricle with significant left-to-right shunt. Cardiac magnetic resonance imaging and computed tomography angiography revealed a massively dilated fistula between the left circumflex coronary artery and the coronary sinus with a diameter of 3-4 cm. The patient underwent combined heart surgery involving mitral ring annuloplasty and fistula ligation and was discharged in stable condition on guideline-based medical therapy. At 18 months of follow-up, minimal residual shunt flow and mild-to-moderate mitral regurgitation were found. We report a rare case of congenital coronary disorder resulting in heart failure and highlight the importance of complex non-invasive cardiac diagnostic procedures before planning and performing heart surgery.

Surgical Treatment of an Aneurysmal Coronary Artery Fistula between the Left Coronary Artery and Right Atrium: A Case Report

“…Following transcatheter closure of the fistula, the patient displayed an improvement in symptoms but also experienced complications from a myocardial infarction. Similarly, Sandor et al [ 6 ] reported a patient with a fistula extending from the left circumflex coronary artery to the coronary sinus, along with a significant left-to-right shunt (Qp/Qs=2.159) and congestive heart failure. After undergoing fistula ligation, the patient was discharged with improved cardiac function.…”

Coronary artery fistula as another cause of acute heart failure

“…Most coronary artery fistulae originate from the right coronary artery (40–60%) and mainly connect to the right atrium, right ventricle or pulmonary trunk [ 3 ] . Although it is a rare congenital or acquired entity, a CAF may present with different signs and symptoms depending on the number, size, location, haemodynamic profile and underlying comorbidities of the patient [ 1 , 3 , 4 ] . Clinical sequelae of CAFs may include dilatation of the heart chamber and dyspnoea, as well as ischaemia symptoms.…”

“…Transthoracic echocardiography showed dilated cardiomyopathy with severe depression transcatheter CAF closure demonstrate that this procedure is effective in most patients with suitable anatomy; however, it is not free of risks. The updated 2018 American College of Cardiology/American Heart Association guidelines recommend transcatheter closure or surgical closure for giant fistulas or when symptoms indicate obvious heart failure [4,5] . In our patient, given the coronary anatomy and large-calibre fistula, surgical intervention was suggested.…”

Intermediate and Long-Term Follow-Up of Transcatheter Closure of Congenital Coronary Cameral Fistulas in Infants and Children: Experience from a Single Center

“…A CCF that drains to the left ventricle (LV) produces hemodynamic changes similar to those of aortic regurgitation, and a CCF that drains to the left atrium (LA) results in volume overload similar to that of mitral regurgitation [6]. If left untreated, CCFs may result in clinical complications, such as myocardial ischemia [7], ventricular dysfunction [8], aneurysmal formation [9], and infective endocarditis [10].…”