Abstract
Coronary artery fistulas represent the most common hemodynamically significant congenital defect of the coronary arteries and the clinical presentation is mainly dependent on the severity of the left-to-right shunt. We describe a case of a 55-year-old man with history of chest pain and without history of previous significant chest wall trauma or any invasive cardiac procedures. A coronary multislice computed tomography showed two large coronary fistulas arising from the left anterior descending coronary artery and ending in an angiomatous plexus draining into the common pulmonary trunk. Coronary angiography confirmed the CT finding and showed a third fistulous communication arising from the sinus node artery.
Although coronary fistulas are infrequent, they are becoming increasingly important because their management and treatment could prevent serious complications. The latest guidelines of the American College of Cardiology/American Heart Association indicate as Class I recommendation the percutaneous or surgical closure for large fistulas regardless of symptoms.
In this manuscript, we provide a detailed review of the literature on this topic, focusing on the clinical management of these patients.
1
Introduction
Coronary artery fistulas (CAF) are congenital or acquired rare abnormal connections from a coronary artery to a cardiac chamber (coronary-cameral fistula), great vessel like pulmonary artery (arteriovenous fistula), aorta (coronary-aortic fistula), or other structure, allowing the blood shunt and the bypass of myocardial capillary network . Coronary fistulas represent the most common hemodynamically significant congenital defect of the coronary arteries and the incidence in general population is 0.002% but coronary angiographic series reveal an incidence of 0.3–0.8%, without race or sex predilection .
2
Case report
A 55-year-old man with history of poor controlled blood pressure and chest pain was admitted to our department for further evaluations. The patient had no positive family history for coronary artery disease, congenital heart disease or sudden cardiac death; there was no history of previous significant chest wall trauma or any invasive cardiac procedures. Previous cardiologic assessments for the chest pain evaluation with exercise treadmill test did not show ischemic changes. For the recurrence of symptoms, after the non-conclusive exercise ECG test, we decided to perform a coronary multislice computed tomography (CT) as indicated in the recent guidelines on myocardial revascularization (in symptomatic patient with intermediate risk, nuclear imaging is indicated in first class, level of evidence A) .
The contrast-enhanced retrospectively ECG-gated coronary CT showed a non-significant left main coronary artery lesion (< 50%) and two large coronary fistulas arising from the left anterior descending coronary artery (LAD), the first one from the proximal portion, the second one from the intermediate portion of the LAD ( Fig. 1 ). The two fistulas terminated in angiomatous plexus, draining into the common pulmonary trunk ( Fig. 2 ).
At admission the patient was asymptomatic and in good physical condition, with a blood pressure of 170/85 mmHg and a heart rate of 90 beats/min. No added sounds or murmurs were heard on cardiac auscultation. The electrocardiogram (ECG) showed sinus rhythm at 90 bpm, PR interval of 0.20 s and a left anterior fascicular block. Transthoracic echocardiography showed a good left ventricular global and segmental function with left ventricular ejection fraction (EF) of about 60% and altered relaxation mitral inflow pattern. The percutaneous coronary angiography confirmed the previous CT findings, showing no significant coronary atherosclerotic lesions and two large coronary artery fistulas with a bigger hemodynamic shunt passing through the second one ( Fig. 3 , panel A). Furthermore the angiograms showed a third fistulous communication, arising from the sinus node artery. Probably the drainage of this fistula should to be located into the mediastinal vessels but, because of its small size and the retroaortic course, it has not been possible to be identified with certainty the drainage ( Fig. 3 , panel B). Given the small size was not considered appropriate to do further investigation.
On the basis of good general clinical condition, the patient refused any further intervention for closure of the fistulas, hence he was treated conservatively with medical therapy. The patient has carried out annual cardiologists check results normal. The follow-up to 5 years confirms the clinical well-being and good control of symptoms through a therapy with beta-blocker, ARB, diuretic and ASA.
2
Case report
A 55-year-old man with history of poor controlled blood pressure and chest pain was admitted to our department for further evaluations. The patient had no positive family history for coronary artery disease, congenital heart disease or sudden cardiac death; there was no history of previous significant chest wall trauma or any invasive cardiac procedures. Previous cardiologic assessments for the chest pain evaluation with exercise treadmill test did not show ischemic changes. For the recurrence of symptoms, after the non-conclusive exercise ECG test, we decided to perform a coronary multislice computed tomography (CT) as indicated in the recent guidelines on myocardial revascularization (in symptomatic patient with intermediate risk, nuclear imaging is indicated in first class, level of evidence A) .
The contrast-enhanced retrospectively ECG-gated coronary CT showed a non-significant left main coronary artery lesion (< 50%) and two large coronary fistulas arising from the left anterior descending coronary artery (LAD), the first one from the proximal portion, the second one from the intermediate portion of the LAD ( Fig. 1 ). The two fistulas terminated in angiomatous plexus, draining into the common pulmonary trunk ( Fig. 2 ).
At admission the patient was asymptomatic and in good physical condition, with a blood pressure of 170/85 mmHg and a heart rate of 90 beats/min. No added sounds or murmurs were heard on cardiac auscultation. The electrocardiogram (ECG) showed sinus rhythm at 90 bpm, PR interval of 0.20 s and a left anterior fascicular block. Transthoracic echocardiography showed a good left ventricular global and segmental function with left ventricular ejection fraction (EF) of about 60% and altered relaxation mitral inflow pattern. The percutaneous coronary angiography confirmed the previous CT findings, showing no significant coronary atherosclerotic lesions and two large coronary artery fistulas with a bigger hemodynamic shunt passing through the second one ( Fig. 3 , panel A). Furthermore the angiograms showed a third fistulous communication, arising from the sinus node artery. Probably the drainage of this fistula should to be located into the mediastinal vessels but, because of its small size and the retroaortic course, it has not been possible to be identified with certainty the drainage ( Fig. 3 , panel B). Given the small size was not considered appropriate to do further investigation.
