Perioperative implications of Coronary–cameral fistula

Coronary–cameral fistulas (CCFs) are mostly congenital in origin and rarely acquired. Clinical symptoms are decided by the hemodynamic significance of the coronary fistula. Even in asymptomatic patients, it is essential to know about coronary CCF particularly if the patient is to undergo cardiac surgery with cardioplegic cardiac arrest. Incidental finding of coronary CCF should never be ignored. Intraoperative myocardial protection and methods used are significantly influenced by such fistula.

Isquemia miocárdica secundaria a fenómeno de robo de flujo por fístulas coronarias: reporte de caso / Myocardial ischemia secondary to flow steal phenomenon by coronary fistulas: case report / Isquemia miocárdica secundária ao fenômeno de roubo de fluxo por fistulas coronárianas: relato de caso

Resumen: Las fístulas coronarias son una comunicación anómala directa entre las arterias coronarias y las cavidades cardíacas o alguno de los vasos sanguíneos próximos al corazón. Son poco comunes, con una incidencia angiográfica entre 0,1%-2%. Dependiendo de la magnitud de robo coronario, pueden ser asintomáticas o causar cuadros clínicos graves con alta repercusión funcional, como isquemia miocárdica, insuficiencia cardíaca congestiva, endocarditis, infecciones recurrentes del aparato respiratorio o en casos raros hipertensión pulmonar. Se presenta el caso de una paciente con fístulas coronarias que ocasionaron isquemia miocárdica por robo de flujo coronario con importante repercusión clínica y hemodinámica. El diagnóstico definitivo se llevó a cabo mediante intervencionismo coronario percutáneo y dadas las características anatómicas de las fístulas, se determinó tratamiento médico.

Summary: Coronary fistulas are an anomalous direct communication between the coronary arteries and one of the four cardiac cavities or one of the blood vessels near the heart, are uncommon with an angiographic incidence between 0.1% - 2%, and, depending of the magnitude of coronary steal, they may be asymptomatic or cause severe clinical symptoms with high functional repercussion, such as myocardial ischemia, congestive heart failure, endocarditis, recurrent respiratory infections or, in rare cases, pulmonary hypertension. We present a case of a female patient with coronary fistulas that caused myocardial ischemia due to coronary flow steal with important clinical and hemodynamic repercussions. The definitive diagnosis was made through percutaneous coronary intervention and given the anatomical characteristics of the fistulas, medical treatment was determined.

Resumo: As fístulas coronarianas são uma comunicação anômala direta entre as artérias coronárias e uma das quatro cavidades cardíacas ou um dos vasos sanguíneos próximos ao coração; são incomuns com uma incidência angiográfica entre 0,1% - 2% e, dependendo da magnitude do roubo coronariano, podem ser assintomáticos ou causar sintomas clínicos graves, com alta repercussão funcional, como isquemia miocárdica, insuficiência cardíaca congestiva, endocardite, infecções respiratórias de repetição ou, em raros casos, hipertensão pulmonar. Apresentamos um caso de uma paciente com fístulas coronarianas que causaram isquemia miocárdica por roubo de fluxo coronariano com importante repercussão clínica e hemodinâmica. O diagnóstico definitivo foi feito por meio de intervenção coronariana percutânea e, dadas as características anatômicas das fístulas, foi determinado tratamento médico.

A Case of Ischemic Angina with Heart Failure due to Congenital Coronary Aterial Anomaly

Coronary artery fistula is an unusual anomaly in elderly patients that consists of a communication bet- ween one of the coronary arteries and other cardiac chambers or veins. It causes many cardiac compli- cations due to hemodynamic changes, and thus has recognized its clinical significance. It occurs usually in congenital origin, but also occurs secondarily in traumatic or neoplastic or artherosclerotic coronary diseases. Congenital coronary artery fistula is a very rare congenital anomaly that results in multiple hemodynamic complications. It has reported rarely in elderly patients, that induces myocardial ischemia due to coronary steal syndrome and heart failure that caused by diastolic volume overload via a left to left shunt. We observed a 68-year-old male patient with exertional chest pain and dyspnea, in whom selective coronary angiography revealed abnormal reticular communication between left anterior descending artery and left circumflex artery and drained to left ventricle through multiple microfistulous channels. We report this patient case who complicated by myocardial ischemia and left ventricular failure those caused by hemodynamic complication due to multiple coronary artery-left ventricular fistulae.

A Case of Ischemic Angina with Heart Failure due to Congenital Coronary Aterial Anomaly

Coronary artery fistula is an unusual anomaly in elderly patients that consists of a communication bet- ween one of the coronary arteries and other cardiac chambers or veins. It causes many cardiac compli- cations due to hemodynamic changes, and thus has recognized its clinical significance. It occurs usually in congenital origin, but also occurs secondarily in traumatic or neoplastic or artherosclerotic coronary diseases. Congenital coronary artery fistula is a very rare congenital anomaly that results in multiple hemodynamic complications. It has reported rarely in elderly patients, that induces myocardial ischemia due to coronary steal syndrome and heart failure that caused by diastolic volume overload via a left to left shunt. We observed a 68-year-old male patient with exertional chest pain and dyspnea, in whom selective coronary angiography revealed abnormal reticular communication between left anterior descending artery and left circumflex artery and drained to left ventricle through multiple microfistulous channels. We report this patient case who complicated by myocardial ischemia and left ventricular failure those caused by hemodynamic complication due to multiple coronary artery-left ventricular fistulae.

A Case of Coronary Steal Syndrome Caused by a Coronary Arteriovenous Fistula: Retrograde Flow from Non-stenotic Left Anterior Descending Artery to Left Circumflex Artery

In general, coronary steal is defined as a fall in blood flow toward a certain vascular region in favor of another area during arteriolar vasodilatation. The coronary artery fistulae is an unusual abnormality in the general population, but is the most common abnormality of the coronary arteries that are ED: Either the ARTERIES ARE hemodynamically significant, or the ABNORMALITY IS hemodynamically significant. Hemodynamically significant. We experienced a 58-year-old male patient with intermittent chest pain at rest. Coronary angiography showed coronary artery fistulae on the LCX and RCA and retrograde flow from the LAD to LCX. Retrograde flow caused coronary artery steal syndrome on LAD territory. A stress/rest MIBI myocardial scan showed reversible ischemia on the LAD territory. He underwent an operation for the coronary artery fistulae, and has since been doing well without chest pain.

Coronary Fistula Anastomosing between Right Coronary Artery and Left Bronchial Artery Accompanied with Cystic Lung Disease

We report a case of 86-year-old woman with coronary artery fistula connecting the right coronary artery and left bronchial artery accompanied with cystic lung disease presenting with dyspnea and chest pain. Coronary angiography revealed that right coronary artery was anastomosed with the collaterals of left bronchial artery at the right hilum and tortuously ascended along the aortic arch and descended connecting with left pulmonary lobar artery at a certain site which is faintly opcified showing to and pro phasic movement. Chest CT scan shows the multicystic changes of the left lower lobe of the lung and hypertrophied bronchial artery of left lobar bronchus. Under the diagnosis of coronary artery fistula, hypertensive heart disease and multicystic lung disease, patient's symptoms and signs were improved by conservative treatment without surgical intervention.

Effects of Nitroglycerin and Dipyridamole on Myocardial Perfusion during Total and Graded Partial Coronary Occlusion in Open Chest Dogs

BACKGROUND: To investigate the effects of nitroglycerin(NTG) and dipyridamoie(DIP) on the perfusion of ischemic myocardium during total occlusion of one coronary vessel and with 3 graded partial occlusion of its collateral supplying vessel, myocardial contrast echocardiography(MC-Echo) was performed on seven pentobarbital anesthetized open chest dogs. METHODS: After a left thoracotomy was done, the left anterior descending coronary artery(LAD) was dissected for ligation to produce total LAD occlusion and left circumflex coronary artery(LCX) was separated to place an electromagnetic flow probe and, distally, screw occluder to restrict LCX flow by 50% and 90% of the preocclusion value. MC-Echo images were made by bolus injections of a 5ml of two-syringe-agitated mixture of sodium meglumine ioxaglate(Hexabrix) and normal saline(2 : 3 by volume) into the aortic root, and then the echocontrast defect area(EDA) with planimeter, peak echocontrast intensity(PEI) and the echocontrast washout halftime(WHT) with videodensitometer were measured. A 100microg of NTG was administered by bolus injection in the aortic root and was followed by 5mg of DIP after the hemodynamic effect of the NTG has been abolished. MC-Echo images were obtained after each infusion of NTG and DIP, first 60 minutes after total LAD occlusion with intact LCX flow, next with a 50% restriction of LCX flow, and third with a 90% restriction of LCX flow. RESULTS: 1) During total LAD occlusion with intact LCX flow : The EDA measured 60 minutes postocclusiom(PO) of LAD(14.2%) was smaller than that 3 minutes PO(20.5%, p<0.01). After NTG, systolic and diastolic blood pressure(BP) was decreased(p<0.01, p<0.05, respectively) and heart rate(HR) was not changed. The mean EDA(15.1%) was not changed, but an increase in EDA occurred in cases of which the diastolic BP fell by more than 20mmHg, and/or the systolic BP was less than 80mmHG after NTG, After DIP, BP and HR were unchanged. The PEI was increased and WHT was shortened in the nonischemic area, reflecting an increase in myocardial perfusion to a normal zone. However, the EDA(17.0%) was increased(p<0.05). The increase in EDA was more prominent in cases with good collaterals. This finding indicates that DIP cases coronary steal from the ischemic myocardium to the normal myocardium through the collaterals. 2) During total LAD occlusion with a 50% restriction of LCX flow : BP and HR were not altered. EDA, PEI and WHT were the same as those taken during intact LCX flow. After NTG, BP was decreased(p<0.01), but HR were not different from baseline values, After DIP, BP and HR remaince unchanged and EDA(16.2%) was increased(p<0.05). PEI was decreased(p<0.05) and WHT was delayed(p=0.054), indicating that DIP impaired any further increase of perfusion in ischemic myocardium. 3) During total LAD occlusion with a 90% restriction of LCX flow : Systolic and diastolic BP were decreased(p<0.05), but HR was unchanged. EDA(20.2%) was increased as compared to those during intact LCX flow(p<0.01). NTG decreased the EDA(17.6%, p<0.05) despite decrease in BP(p<0.01), while DIP did not alter the hemodynamics or EDA(20.7%). The PEI and WHT after infusion of both NTG and DIP were not different from baseline values. CONCLUSION: 1) Dipyridamole causes coronary steal from ischemic myocardium when the flow of collateral supplying vessel is intact or restricted by 50%, but not during 90% restriction of flow, suggesting the degree of stenosis of collateral supplying vessels is a determinant of coronary steal. 2) The beneficial effect of nitroglycerin to ischemic myocardium was largely determined by the extent of collateral flow and its effect on hemodynamics.