Surgical treatment for a case of coronary steal from a traumatic coronary artery-cameral fistula after blunt cardiac injury.

INTRODUCTION: Blunt cardiac trauma covers a spectrum of injuries from clinically insignificant myocardial contusions to lethal ruptures of cardiac valves and chambers. Traumatic coronary artery-cameral fistulas (TCAF) are a rare sequelae of blunt chest trauma. CASE PRESENTATION: A 53-year-old male developed a TCAF after a motor vehicle collision. He was found on admission to be in cardiogenic shock with an elevated troponin and intermittent bifascicular block. An echocardiogram revealed hypokinesis of the mid-anteroseptal myocardium with an ejection fraction of 50%. Cardiac catheterization revealed a pseudoaneurysm of the left anterior descending artery (LAD) with a fistulous connection to the right ventricle, shown to be associated with reversible anterior wall ischemia from distal LAD coronary steal phenomenon on a nuclear perfusion scan. Given the ischemic burden, he was treated with operative revascularization via a single vessel coronary artery bypass graft (CABG) using the left internal mammary artery to LAD. DISCUSSION: Early repair of TCAF can halt the progression of complications like left-to-right shunting, pulmonary hypertension, and heart failure. The two best described operative approaches to surgical closure of the fistula are either via external ligation or direct repair from within the recipient chamber, possibly with bypass grafting distal to the fistula site. Transcatheter closure and conservative management has been described for select patients with iatrogenic fistulas in recent literature. CONCLUSION: High levels of clinical suspicion are necessary for the early detection and intervention of TCAF. Surgical or transcatheter interventions including fistula ligation and CABG can prevent later complications of heart failure.

Percutaneous closure of an iatrogenic atrial septal defect.

The use of the Tandem Heart percutaneous ventricular assist device (Tandem Heart pVAD, Cardiac Assist technologies, Pittsburgh, PA) as a bridge to recovery or to other cardiopulmonary support systems has been rising. One requirement for placement of this device is an intraatrial septostomy which is usually closed during the surgical insertion of more permanent ventricular assist devices. We present a case of a 62-year-old man with a residual acquired atrial septal defect (ASD) from Tandem Heart placement, which could not be closed surgically during insertion of left and right ventricular assist devices. The patient remained intubated and hypoxemic after removal of his right ventricular assist device due to the presence of persistent right to left shunting. With closure of the ASD using an 8-mm Amplatzer septal occluder (ASO; AGA Medical Corp., Golden Valley, MN) the patient stabilized and was successfully extubated.

Rheolytic percutaneous thrombectomy for acute pulmonary embolism in a pediatric patient.

Acute massive pulmonary embolism can have significant hemodynamic effects in both adults and children. We describe the case of a 10-year-old boy who developed cardiogenic shock after suffering a massive pulmonary embolism. A significant thrombus burden was removed using a catheter-based strategy of rheolytic thrombectomy, leading to stabilization of the patient.