Echocardiographic diagnosis of congenital coronary artery abnormalities in a continuous series of adolescent football players.

BACKGROUND: Sudden cardiac death (SCD) in children and adolescents is rare. Several studies have reported a higher risk of SCD during athletic competition. High risk congenital coronary artery abnormalities are the second leading cause of SCD in young athletes in the USA. Echocardiographic assessment of coronary arteries has not been routinely used in screening programmes for junior athletes so far. DESIGN: Prospective cohort study in 1045 consecutive adolescent elite football players. METHODS: All athletes underwent a standardized cardiovascular screening protocol with a medical history, a physical examination, 12-lead resting electrocardiogram and a complete transthoracic 2D-echocardiography. RESULTS: Two athletes (0.19%) showed a high-risk coronary artery abnormality (CAA) with a right coronary artery originating abnormal from the aorta and coursing inter-arterial. Low-risk CAAs were found in 16 athletes (1.53%). There was an ectasia of the left coronary artery (+3.9z and +4.3z) and a fistula from the left coronary artery in two cases (0.19%), respectively. In 1.05% ( n = 11) we found a high take-off (2.3-6.8 mm) and in one case (0.096%) there was a tangential take-off of the right main coronary artery. Variants of coronary arterial anatomy were identified in 335 of 1045 athletes (32.06%). CONCLUSION: Basic pre-participation screening tests including 12-lead or exercise electrocardiogram do not safely identify high-risk CAAs. In adolescent athletes an expert cardiologist is able to describe the origin and the proximal course of the coronary arteries and identify major abnormalities in most of the cases by transthoracic 2D-echocardiography.

Late outcome of repair of congenital coronary artery fistulas--a word of caution.

OBJECTIVES: We reviewed our experience with repair of congenital coronary artery fistulas. METHODS: From June 1983 to December 2009, 46 patients (median age, 59 years; range, 1-84 years) underwent surgical repair. The presenting symptoms included angina in 16 patients (35%), congestive heart failure in 11 (24%), and bacterial endocarditis in 5 (11%). Preoperatively, 9 patients (20%) had at least moderate tricuspid regurgitation. Coronary artery dominance was right in 38 patients (83%). Coronary artery aneurysms were found in 8 patients (17%). The most common pattern was right coronary artery-to-coronary sinus fistula (18 patients, 39%); 11 patients had (23%) more than 1 fistula. One patient had undergone previous coil embolization. RESULTS: Cardiopulmonary bypass was used in 39 patients (85%), with extracardiac and intracardiac repair performed in 30 (65%) and 16 (35%), respectively. The most common associated procedures were coronary artery bypass in 13 patients (28%). Early mortality occurred in 1 patient (2%). Postoperative myocardial infarction occurred in 5 patients (11%); 4 of these patients underwent simple ligation or division of their fistulas. The mean follow-up was 6 ± 5.8 years (maximum, 22 years). Late mortality occurred in 11 patients (24%). Two patients underwent reoperation for severe tricuspid regurgitation. Survival was significantly reduced compared with the age- and gender-matched population (P = .03). Residual fistulas were detected in 3 patients (6%), with no reintervention needed. CONCLUSIONS: Perioperative myocardial infarction is an important complication of ligation of coronary artery fistulas and can contribute to reduced late survival. The tricuspid valve should be evaluated carefully at repair because of the relatively high rate of residual regurgitation in survivors.

Angiographic and clinical manifestations of coronary fistulas in Chinese people: 15-year experience.

BACKGROUND: Coronary artery fistula (CAF) is an anomaly resulting in the steal phenomenon of coronary blood flow, which may cause morbidity or mortality. CAFs in Chinese patients after long-term follow-up of 15 years were retrospectively analyzed. METHODS AND RESULTS: From September, 1992 to August, 2007, 152 CAFs were detected in 28,210 coronary angiograms from 125 patients. Clinical and angiographic data of all patients were analyzed retrospectively. Two types of CAFs were characterized: type I in 99 patients with 124 solitary coronary to cardiac chamber or great vessel fistula; type II: 26 patients with 28 coronary artery--left ventricular multiple microfistulas. Single-, double-, and triple-CAFs were detected in 79%, 20%, and 1% of patients, respectively. Coexistent coronary lesions were noted in 41% of patients. Fistula-related symptoms included stable angina in 55, myocardial infarction in 2, heart failure in 2, sudden death with ventricular fibrillation in 1, and syncope in 1. Twenty-four patients had coexistent congenital anomalies. Only 9 patients underwent coronary intervention or/and surgery for CAFs. CONCLUSIONS: CAFs may cause trivial or lethal cardiac events, and may coexist with coronary lesion or congenital anomaly. Coronary to cardiac chamber or great vessel fistula and coronary-left ventricular multiple microfistulas have different morphologic and pathological phenomena.

Coronary artery fistulas in pulmonary atresia and ventricular septal defect.

Pulmonary atresia with ventricular septal defect is an anomaly with highly variable anatomy. Rarely, a coronary artery-to-pulmonary artery fistula may contribute to pulmonary blood flow. Since 1996, we have treated 4 patients with coronary-pulmonary fistula associated with pulmonary atresia and ventricular septal defect. Two fistulas originated from the left coronary, one from the right coronary, and one from a right-sided solitary coronary system. All terminated in the main pulmonary artery, which was adequate in all cases. The fistulas were managed by direct internal closure. Total intracardiac repair was then accomplished in all patients at the same sitting. There was one death. In children with favorable anatomy, direct closure of the fistula from the pulmonary artery is adequate and allows single-stage intracardiac repair.

Angiographic findings and surgical treatments of coronary artery involvement in Takayasu arteritis.

BACKGROUND: Takayasu arteritis is associated with a low incidence of coronary artery involvement, such as stenosis, obstruction, aneurysm, and coronary steal syndrome, but coronary ischemia can be fatal. METHODS: Between 1972 and April 2001, 81 of 130 patients given a diagnosis of Takayasu arteritis underwent selective coronary angiography, and among them, 31 patients (4 male and 27 female patients; mean age, 41.1 +/- 13.2 years) had abnormal coronary angiographic findings and were recruited for this study. RESULTS: Abnormal coronary findings consisted of 24 coronary artery stenoses of greater than 75%, 3 coronary artery-bronchial artery anastomoses, 3 aneurysmal coronary ectasias, and 1 combined coronary ectasia and anastomosis. Among 24 patients with coronary stenosis, the ostium was most frequently involved (87.5%). Twenty-three of 24 patients with coronary artery stenoses were treated surgically. The mean follow-up duration was 9.65 +/- 6.9 years, with a 100% follow-up rate. Four fistulas and 4 aneurysms in 7 patients were not treated surgically. Coronary steal phenomenon was always associated with occluded pulmonary arteries and pulmonary hypertension. Aneurysmal coronary ectasia was related to severe aortic hypertension with or without aortic regurgitation and atypical coarctation. There were 2 (8.7%) in-hospital deaths and 3 (13%) late deaths. The actuarial survival rate, including in-hospital deaths, was 86.5% +/- 7.3% at 5 years and 81.4% +/- 8.4% at 10 years. CONCLUSION: The incidence of coronary abnormalities is relatively low in patients with Takayasu arteritis; however, surgical treatment is recommended for patients with coronary ostial stenoses because coronary ischemia can be one of the major causes of death.

[Diagnosis and therapy of second aortoenteric fistulas: results of 16 patients]. / Diagnostik und Therapie von sekundären aortointestinalen Fisteln. Ergebnisse von 16 Patienten.

From January 1977 to July 1997, 16 patients with aorto/iliac-enteric fistulas underwent repair. The fistula became apparent at a mean of 51 months. Gastrointestinal bleeding was the main symptom in 11 cases, 4 patients had a cutaneous fistula, and 1 developed retroperitoneal bleeding. The preoperative diagnosis was established in one-half of the cases. Three patients had to be treated surgically on an emergency basis without a preoperative diagnosis because of bleeding, 7 patients were semi-urgent and 6 had elective surgery. In 3 cases treatment consisted only of local repair. In 6 patients we performed extra-anatomic revascularization and in 7 patients we achieved restoration by in situ replacement after removal of all infected prosthetic material. Eight of 16 patients survived the perioperative period. Local repair alone cannot be recommended. All 3 patients died. The mortality rates between extra-anatomic revascularization and in situ reconstruction are comparable.