Anaesthetic management of a parturient with an unrepaired coronary arteriovenous fistula for caesarean section.

Coronary arteriovenous fistulas are an abnormal conduit between a coronary artery and another cardiovascular lumen, without an intervening capillary bed. The reported prevalence is 0.002-0.3%. Physiologic consequences such as congestive heart failure, coronary steal phenomenon and fistula aneurysm formation and rupture are possible. There are limited reports of symptomatic coronary arteriovenous fistulas in association with pregnancy. We describe a 19-year-old woman with symptomatic left circumflex artery to coronary sinus fistula, terminating into a large exophytic varix in the right atrium, presenting for an elective caesarean section at 37 weeks gestational age. Our anaesthetic management strategy aimed to optimise myocardial perfusion, maintain euvolemia, avoid right ventricular obstruction from exophytic varix and avoid sympathetic stimulation or sudden increases in pulmonary vascular resistance. A slowly titrated epidural was used as the primary anaesthetic. Our patient tolerated the procedure well and was discharged home on postoperative day two. Understanding of the potential physiologic consequence of coronary arteriovenous fistulas, and interaction with the physiologic changes of pregnancy and delivery, are essential for the management of these cases.

Acute Myocardial Infarction After Surgical Closure of Coronary Artery Fistula: Importance of Anticoagulant Therapy.

We present a case of a coronary arteriovenous fistula between the left circumflex (LCX) and the atrium with LCX ectasia. Four months after surgical closure of the fistula, the patient experienced acute myocardial infarction caused by thrombosis in the LCX. Antiplatelet drugs were replaced with anticoagulant agents, and the patient was followed up without adverse events. (Level of Difficulty: Advanced.).

Surgical Correction of Coronary Arteriovenous Fistula in the Newborn Period / 日本心臓血管外科学会雑誌

Coronary arteriovenous fistula (CAVF) is defined as an abnormal communication between the coronary artery and a cardiac cavity or a major blood vessel. It is the most common congenital anomaly of the coronary arteries, but it is relatively rare, accounting for only approximately 0.4% of all congenital heart diseases. Most cases of CAVF are clinically asymptomatic in young patients, but with increasing age, symptoms begin to appear and surgical treatment is required. In rare cases of CAVF, however, symptoms may appear in the neonatal period and early surgery may be required. In this article, we report the case of a 12-day-old patient diagnosed after birth with CAVF between the aneurysmatic left anterior descending artery and the right ventricle. This patient required early surgical intervention due to concerns about worsening heart failure and developing coronary artery ischemia. Although various surgical options were considered, we opted for an arteriotomy of the left anterior descending artery and closed the fistula with two autologous pericardial patches. There has been no signs of postoperative ischemic changes or enlargement of the coronary aneurysm during the 4 years of follow up, and careful monitoring will continue.

Iatrogenic Arteriovenous Fistula Secondary to Coronary Artery Dissection Caused by Contrast Injection Into a Chronically Occluded Right Coronary Artery.

Coronary arteriovenous fistulas and coronary cameral fistulas are rare anomalies that involve the abnormal communication between a coronary artery and a venous structure, such as a coronary vein or a right-sided cardiac chamber. Iatrogenic coronary arteriovenous fistulas and coronary cameral fistulas can be uncommon complications of coronary artery angiography and intervention. Acquired coronary arteriovenous fistulas that develop during percutaneous coronary intervention of chronic total occlusions have been previously reported in the literature. However, a coronary arteriovenous fistula resulting from contrast injection into a chronically and totally occluded right coronary artery during diagnostic coronary angiography is very rare. We present a unique case of a contrast-induced iatrogenic right coronary dissection leading to a coronary arteriovenous fistula communicating to the right atrium through the middle cardiac vein.

Long-term outcomes following surgical repair of coronary artery fistula in adults.

BACKGROUND AND AIM OF THE STUDY: Coronary artery fistula (CAF) is a relatively rare cardiac anomaly. We investigated long-term outcomes following surgical repair of CAF in adults. METHODS: We retrospectively investigated 13 consecutive patients undergoing surgical repair of CAF in our institution between 2008 and 2019 (67.3 ± 10.4 years old, 38% male). CAF types were coronary artery-pulmonary artery fistula (77%), coronary artery-coronary sinus fistula (15%), and both (8%). CAFs originated from the left coronary artery (38%), right coronary artery (8%), and bilateral coronary arteries (38%). Pulmonary and systemic flow (Qp/Qs) was measured in seven patients (54%), with a mean value of 1.52. Seven patients underwent surgery for CAFs alone, and others simultaneously underwent surgery for comorbid cardiac diseases. RESULTS: All procedures were conducted under cardiopulmonary bypass. Surgical procedures were direct epicardial ligation of fistula (92%), direct closure of CAF through pulmonary artery incision (38%), direct closure of CAF through coronary sinus incision (8%), or patch closure of CAF through coronary artery incision (8%). Myocardial perfusion scintigraphy showed asymptomatic myocardial ischemia in the right coronary area after surgery in one patient. There were no deaths perioperatively or during follow-up (mean: 66.6 months). There were no coronary or other CAF-related events. CONCLUSIONS: Several anatomical variations in CAF were observed which coexist with cardiac disease. Long-term outcomes following surgical repair were satisfactory, and the concurrent intervention of CAFs during surgery for comorbid cardiac disease is useful to prevent future complications related CAFs in adults.

Case of rheumatic mitral stenosis with bilateral coronary artery fistula to pulmonary artery: A rare entity.

Coronary to pulmonary artery fistula is a rare form of congenital coronary artery anomaly. Majority of coronary arteriovenous fistula detected incidentally on coronary angiography. Although, most of these patients are asymptomatic, larger fistulae can produce symptoms of heart failure. Here we present a rare case of 61-year-old female who presented primarily for mitral valve replacement for severe mitral stenosis. On screening angiography, there were two fistula arising from both right and left coronary artery and draining in to the main pulmonary artery. The patient was operated and mitral valve replacement with closure of the fistula. Patient had an uneventful post-operative period and was discharged on 7 the post-operative day.

The first multicentre study on coronary anomalies in the Netherlands: MuSCAT.

BACKGROUND: Current guidelines on coronary anomalies are primarily based on expert consensus and a limited number of trials. A gold standard for diagnosis and a consensus on the treatment strategy in this patient group are lacking, especially for patients with an anomalous origin of a coronary artery from the opposite sinus of Valsalva (ACAOS) with an interarterial course. AIM: To provide evidence-substantiated recommendations for diagnostic work-up, treatment and follow-up of patients with anomalous coronary arteries. METHODS: A clinical care pathway for patients with ACAOS was established by six Dutch centres. Prospectively included patients undergo work-up according to protocol using computed tomography (CT) angiography, ischaemia detection, echocardiography and coronary angiography with intracoronary measurements to assess anatomical and physiological characteristics of the ACAOS. Surgical and functional follow-up results are evaluated by CT angiography, ischaemia detection and a quality-of-life questionnaire. Patient inclusion for the first multicentre study on coronary anomalies in the Netherlands started in 2020 and will continue for at least 3 years with a minimum of 2 years of follow-up. For patients with a right or left coronary artery originating from the pulmonary artery and coronary arteriovenous fistulas a registry is maintained. RESULTS: Primary outcomes are: (cardiac) death, myocardial ischaemia attributable to the ACAOS, re-intervention after surgery and intervention after initially conservative treatment. The influence of work-up examinations on treatment choice is also evaluated. CONCLUSIONS: Structural evidence for the appropriate management of patients with coronary anomalies, especially (interarterial) ACAOS, is lacking. By means of a structured care pathway in a multicentre setting, we aim to provide an evidence-based strategy for the diagnostic evaluation and treatment of this patient group.

Coronary anomalies in tetralogy of Fallot - A meta-analysis.

BACKGROUND: An anomalous coronary artery is reported in 2% to 23% of patients with tetralogy of Fallot (TOF). Knowledge of coronary anatomy prior to corrective surgery is vital to avoid damage to vessels crossing the right ventricular outflow tract (RVOT). A meta-analysis on the prevalence of anomalous coronary arteries in TOF is lacking to date. Here, an overview of coronary anomalies in TOF is provided and implications for patient management are discussed. METHODS: PubMed, Embase and Web of Science were searched. Analysis was done using Revman 5.3 (Cochrane Community, London). The primary analysis focused on the origin and proximal course of the right and left coronary arteries. In addition, the prevalence of large conus arteries and coronary arteriovenous fistulas (CAVF) was calculated. RESULTS: Twenty-eight studies, encompassing 6956 patients, were included; 6% of TOF patients have an anomalous coronary artery. Hereof, 72% cross the RVOT; the majority of the remaining 28% courses behind the aorta. Six percent of patients have a large conus artery and 4% a CAVF. Other coronary anomalies include a left or right coronary artery from the pulmonary trunk or left or right pulmonary artery, coronary tree hypoplasia and anastomoses between coronary and bronchial arteries. CONCLUSIONS: The prevalence of coronary anomalies in TOF is 4-6%. In patients with an anomalous coronary artery, 72% cross the RVOT. The combined risk of encountering an anomalous coronary artery or a large conus artery crossing the RVOT is 10.3%. Coronary anatomy should be defined before surgery and the surgical approach adapted accordingly.

Surgical treatment of a left anterior descending artery to the main pulmonary artery fistula.

We report a case of surgical treatment of a 58-year-old symptomatic patient with large coronary artery fistula, which drained from the left anterior descending artery into the main pulmonary artery (PA), and concomitant large patent foramen ovale. The surgery was performed through a median sternotomy with aortobicaval total cardiopulmonary bypass. The PA was incised. The fistula was identified 5 mm above the anterior leaflet of the pulmonary valve and was closed off using a prolene suture. Afterward, the atrium septum defect was closed with a Dacron patch via the standard right atrium access. There were no postoperative complications.

Cardiac tamponade due to rupture of a giant coronary artery aneurysm with a coronary arteriovenous fistula: a case report.

BACKGROUND: Coronary artery aneurysm (CAA) is defined as dilatation exceeding 1.5 times the width of the normal adjacent coronary artery segments. CAA usually causes few symptoms, and rupture is rare, but can be lethal due to cardiac tamponade when it does occur. CASE PRESENTATION: A 79-year-old woman presented with presyncope and back pain. Emergency surgery was performed based on a diagnosis of cardiac tamponade due to either rupture of coronary arteriovenous fistula or CAA. At surgery, a rupture site was located on the wall of the giant CAA, with a diameter of 55 mm, originating from the ostium of the right coronary artery. Suture closure of the inflow and outflow of the aneurysm was performed, and the aneurysmal cavity was obliterated by multiple sutures. The patient made an uneventful recovery and was discharged from hospital on postoperative day 13. CONCLUSION: On the basis of this case, we propose considering rupture of a CAA as one of the causes of cardiac tamponade.

Surgical management of proximal coronary arteriovenous fistulas using intraoperative fluorescence imaging.

We report the use of intraoperative fluorescence imaging to assist in the surgical management of proximal coronary arteriovenous fistulas in four patients.

Inadvertent anastomosis of the left internal mammary artery to the great cardiac vein.

We present an uncommon and underreported complication of coronary artery bypass graft surgery: erroneous anastomosis of the left internal mammary artery to the great cardiac vein. The iatrogenic aorto-coronary arteriovenous fistula with left-to-right shunting resulted in dilation of the coronary sinus, a supporting secondary finding. Factors predisposing to this inadvertent anastomosis include an intramyocardial segment of the left anterior descending coronary artery, demonstrated in this case, as well as epicardial fat and potentially fibrosis of the underlying myocardium.

Right coronary artery ectasia with coronary arteriovenous fistula mimicking Takotsubo-like left ventricular dysfunction in the electrocardiogram.

A coronary arteriovenous fistula is an abnormal connection between a coronary artery and any of four chambers in the heart. We repot a unique case with a fistulae originating from right coronary artery and draining into the right atrium via coronary sinus although Takotsubo-like left ventricular dysfunction or acute myocardial infarction was initially thought to have occurred according to the electrocardiogram finding.

Multiple right coronary artery fistulas to coronary sinus: A case report and literature review.

BACKGROUND: Coronary arteriovenous fistula is a rare congenital or acquired abnormal connection between a coronary artery and any of the great vessels or any of the heart chambers. Most of them are diagnosed during routine coronary angiography. CASE REPORT: This case report illustrates a successful surgical ligating of multiple right coronary artery and circumflex artery fistulas to coronary sinus. CONCLUSION: According to our experience and literature review, it can be concluded that to prevent potential complications in various cases of coronary arteriovenous fistula, early surgical management, just after their condition has been diagnosed, is the best choice.

Clinical presentation of coronary arteriovenous fistula according to age and anatomic orientation.

BACKGROUND: Coronary arteriovenous fistulas (CAVFs) are direct connections from one or more coronary arteries to cardiac chambers or a large vessel. They are mostly of congenital origin. The aim of this study was to describe clinical presentation and also delineate the course and management of CAVF. METHODS: Clinical data, chest x-rays, echocardiographic and angiographic evaluation of 40 patients with congenital CAVF during 1990 to 2008 were reviewed retrospectively. RESULTS: Seventeen patients were ≤ 20 years old (42.5%) were mostly asymptomatic, and twenty tree cases were older than 20 years old (57.5%), mostly symptomatic (P<0.05). Twenty one (52.5%) patients had pure CAVF and nineteen (47.5%) patients with associated intarcardiac congenital heart disease (15%) or acquired valvular and coronary arteries diseases (32.5%). CAVFs mostly originated from left anterior descending artery (LAD) (42.5%) and mostly drained into the main pulmonary artery (MPA) (35 %). Twenty-four patients underwent CAVF surgical ligation. From twenty-one patients with pure CAVF, eight (38%) patients were complicated by congestive heart failure and aneurism formation of fistula. CONCLUSION: Unlike some previous reports, in our study, the most prevalent origin site for CAVFs was the left anterior descending (LAD). Most patients with CAVFs especially those who went first diagnosed before 20 years old were asymptomatic. On the other hand, as the continuous murmur is not always detected in children or infants, consequently, cases of spontaneous closure may remain undetected. All symptomatic and asymptomatic patients with moderate to severe shunting should be operated on and minimal morbidity and good surgical results could be expected.

Ruptured Coronary Aneurysm with a Congenital Coronary Arteriovenous Fistula / 日本心臓血管外科学会雑誌

An 83-year-old man was transferred to our hospital with cardiac tamponade and suspected cardiac tumor detected by enhanced CT. Coronary angiography showed a coronary aneurysm of 50 mm ID on the left circumflex artery. An emergency surgery was performed to excise the aneurysm, and a fresh thrombus occupying the efferent artery was observed. Both the afferent and efferent vessels were closed by suture. The patient made an otherwise uneventful recovery. This case featured a fresh red thrombus formed in fistulous outflow of the coronary aneurysm that seemed a direct cause of rupture.

Coronary arteriovenous fistulas complicated by complete atrioventricular block: A case report.

We report the case of a patient with bilateral coronary arteriovenous fistulas (CAVFs) connecting the right coronary artery and left circumflex coronary artery with the right atrium who had progression of first-degree atrioventricular (AV) block to complete AV block during a 4-year period. The His bundle electrogram revealed that the complete AV block was the result of a block at the level of the AV node. Dipyridamole stress thallium-201 myocardial imaging showed decreased perfusion in the inferoapical wall. Coronary angiography and computed tomography showed fistulas that arose from the AV nodal branch of the right coronary artery and from the distal portion of the circumflex coronary artery and drained into the right atrium. Because the fistulas were small, they were not repaired surgically, and a permanent pacemaker was implanted to treat the complete AV block. We presumed that the complication by complete AV block was due to abnormalities of the arteries feeding the AV node and chronic ischemia resulting from a coronary steal associated with the fistulas. To the best of our knowledge, this is the first report of CAVF complicated by complete AV block.

Left circumflex coronary arteriovenous fistula presenting as acute coronary syndrome.

Coronary arteriovenous fistula (CAVF) is a rare congenital anomaly that is seen in 0.1-0.2% of coronary angiograms. A 79-year-old man with no risk factors for coronary artery disease, presented with unstable angina and normal clinical examination. Coronary angiogram revealed a large left circumflex coronary artery with multiple aneurysms exiting into right atrium. Although coil embolization was feasible, he was managed conservatively as he responded to medications. This case shows that large CAVF can be asymptomatic up to the 7th decade of life, manifest as acute coronary syndrome, can present without any murmur on auscultation, and medical management can be effective.