Abstract 13531: Coronary-Cameral Fistulae Causing Coronary Steal Syndrome Inducing Polymorphic Ventricular Tachycardia

Abstract

Background: Coronary-cameral fistulae are rare, and usually benign, anomalous connections between coronary artery and cardiac chambers. These fistulae are rarely large enough to cause ischemia, arrhythmia, and heart failure. Case: A 49 year-old female with a complicated medical history including numerous systemic arteriovenous malformations, high output heart failure, hypertrophic cardiomyopathy with MRI proven myocardial fibrosis, recurrent monomorphic ventricular tachycardia (VT), defibrillator placement, with recent VT ablation and sympathectomy presented to the coronary care unit for recurrent monomorphic VT. During her CCU course, this patient developed a distinctly different, incessant polymorphic VT with progression to ventricular fibrillation (VF). Decision-making: The patient was started on a procainamide infusion in addition to her amiodarone infusion. Her device pacing rate was increased to improve systemic perfusion. Unfortunately, this appeared to worsen the burden of polymorphic VT. She underwent emergent cardiac catheterization, which demonstrated multiple coronary cameral fistulae arising from all three major coronary vessels with brisk flow into the left ventricular cavity, concerning for coronary steal syndrome causing ischemia. To improve coronary diastolic filling time, the pacing rate was decreased. The largest fistula, the distal PDA to left ventricle, was embolized. She remained free of polymorphic VT for 13 days, but ultimately died due to complications of aspiration pneumonia with septic shock and multiorgan system failure. Conclusion: Acute myocardial ischemia is a common cause of polymorphic ventricular tachycardia. In this medically complicated patient with history of monomorphic VT suspected secondary to myocardial scar, her polymorphic VT was likely precipitated by the coronary-cameral fistulae causing coronary steal syndrome with improvement of her polymorphic VT after embolization and slowing heart rate with ischemia reduction.