Transcatheter coil closure of a congenital coronary arterial fistula

Abstract

Congenital coronary arterial fistulas to atria1 or ventricular chambers are an uncommon form of heart disease that requires surgical closure in chi1dhood.l Conventional management includes a thoracotomy with either epicardial closure of the fistula, or with cardiopulmonary bypass and cardiotomy to close the site of drainage.2 Transcatheter coil embolization, utilized for the closure of “unwanted” vascular communications such as bronchial collaterals, arteriovenous malformations, or Blalock-Taussig shunts,3T 4has not been used as treatment for congenital coronary arterial fistulas. This report describes the use of Gianturco spring coil embolization in a 13-month-old child with a large right coronary arterial-to-right atrial fistula. Complete closure was accomplished in the cardiac catheterization laboratory, obviating the need for surgical correction. This is the first report and description of the technique for this alternative form of therapy. A 13-month-old girl was referred for evaluation of a continuous murmur and slow weight gain. Her weight was 7.7 kg (less than the fifth percentile) with a body length of 76 cm (fiftieth percentile). On physical examination she was a small infant without evidence of respiratory distress. The cardiac impulse was mildly hyperdynamic. Si was normal and Ss was split with a normal pulmonic component. There was no Ss, S4, or ejection click. There was a grade II to III/ VI continuous machinery murmur heard at the left midsternal border with a grade II/VI mid-diastolic rumble at the apex. The liver was palpable 3 cm below the right costal margin. The femoral pulses were bounding. Electrocardiogram revealed a normal sinus rhythm with right ventricular conduction delay and left ventricular hypertrophy. The chest x-ray film showed mild cardiac enlargement with increased pulmonary blood flow and a prominent right atria1 shadow. A two-dimensional echocardiogram with color-flow Doppler demonstrated a large coronary arterial fistula that arose near the ostia of the right main coronary artery. This fistula was tortuous and coursed to the right atrial-superior vena caval junction near the interatrial groove, and drained through multiple small fenestrations into the right atrium. The right ventricle was dilated, consistent with a volume overload, and there was no evidence of a patent ductus arteriosus. At cardiac catheterization there was a moderate left-to-right shunt with a Qp/Qs