Coronary Artery Fistulas In Adults Research Articles

Diagnosis and Management of Congenital Coronary Artery Fistulas in Adults.

This review describes the presentation, diagnosis, and management of congenital coronary artery fistulas (CAFs) in adults. CAFs are classified as coronary-cameral or coronary arteriovenous fistulas. Fistulous connections at the distal coronary bed are more likely to be aneurysmal with higher risk of thrombosis and myocardial infarction (MI). Medium-to-large or symptomatic CAFs can manifest as ischemia, heart failure, and arrhythmias. CAF closure is recommended when there are attributable symptoms or evidence of adverse coronary remodeling. Closure is usually achievable using transcatheter techniques, though large fistulas may require surgical ligation with bypass. Given their anatomic complexity, cardiac CT with multiplanar 3-D reconstruction can enhance procedural planning of CAF closure. Antiplatelet and anticoagulation are essential therapies in CAF management. CAFs are rare cardiac anomalies with variable presentations and complex anatomy. CAF management strategies include indefinite medical therapy, percutaneous or surgical CAF closure, and lifelong patient surveillance.

Prevalence of coronary artery fistula in adults performing coronary CT angiography among Egyptian population: a single center study

BackgroundThe prevalence of coronary artery fistula (CAF) among Egyptian population is increasing due to widespread availability of coronary CT angiography using high-end CT scanners. The purpose of this observational study was to determine the incidence and types of CAF detected among Egyptian population during routinely performed coronary CT angiography.ResultsAmong the 2263 retrospectively evaluated CT coronary angiography studies, CAF was detected only in 17 (0.75%) patients with proximal LAD being the commonest vessel of origin; in 5 cases (29.4%) and main pulmonary artery (MPA) the commonest site of fistula termination; in 3 cases (17.6%). Indeterminate site of fistula termination was present in two cases (11.7%) due to limited scan coverage.ConclusionsMultislice coronary CT angiography is a useful non-invasive imaging modality for diagnosis of CAF by demonstrating vessel of origin, course and site of termination, with CAF prevalence and types among Egyptian population being reported in this study based on routinely performed coronary CT angiography.

Prevalence and characteristics of coronary artery fistula in adults: coronary angiographic analysis of 18,106 patients.

Aim Coronary artery fistula (CAF) is a rarely encountered anomaly that is characterized by an abnormal connection between a coronary artery and a cardiac chamber or a great thoracic vessel. Its incidence has not been precisely established due to the large number of undiagnosed cases and it shows heterogeneity in its anatomic configuration and clinical consequences. We aimed to assess the frequency, imaging findings, and clinical features of CAF among patients in our tertiary medical center.Material and methods The angiographic data of 18,106 consecutive adult patients who underwent coronary angiography between January 2011 and June 2013 were retrospectively analyzed.Results CAF was detected in 22 patients (0.14 %). Of these, 5 patients had bilateral fistulas (23 %). 65 % of the fistulas originated from the left anterior descending coronary artery,and 53 % drained into the pulmonary artery. The left ventricle and left atrium were the only drainage sites for left-sided coronary artery fistulas. One patient with a CAF presented with non-ST elevated myocardial infarction in the absence of an evident thrombosis.Conclusion Unlike previous reports, bilateral CAFs were more commonly encountered in this study. Contrary to most of the data in the literature, more than half of the CAFs originated from the left anterior descending coronary artery and most drained into the pulmonary artery. Rare anatomic types of CAFs were also detected.

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

Coronary artery fistula (CAF) is a relatively rare cardiac anomaly. We investigated long-term outcomes following surgical repair of CAF in adults. 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. 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. 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.

Coronary Artery Fistulas in Adults: Evaluation with Coronary CT Angiography

Coronary Artery Fistulas in Adults: Evaluation with Coronary CT Angiography

Coronary artery fistula in adults: Incidence and appearance on cardiac computed tomography and comparison of detectability and hemodynamic effects with those on transthoracic echocardiography

BackgroundThe widespread use of cardiac computed tomography (CT) has increased the incidental discovery of fistulas of the coronary artery (CAF). This condition is rare and can affect hemodynamic parameters, but few reports focus on its hemodynamic effects. We investigated the frequency and types of CAF on CT and compared them with those of transthoracic echocardiography (TTE) to evaluate the detectability of CAF and its hemodynamic effects. Materials and methodsWe retrospectively evaluated cardiac CT images of 6789 adult patients who underwent imaging from January 1, 2013 through September 30, 2019 at our institution. We assessed the CT images for the presence of CAF and compared our findings with those obtained by TTE in control cases without CAF. ResultsThe prevalence of CAF determined with cardiac CT was 0.91%, with the left anterior descending artery (67.7%) as the most common site of origin and the main pulmonary artery (82.3%) as the most common origin of drainage. The incidence of aneurysm accompanying CAF was 48.4%. Color Doppler in TTE demonstrated abnormal flow that would suggest the presence of CAF of only 23.1%. Echocardiographic findings of hemodynamics did not differ significantly between patients with and without CAF nor between elderly and non-elderly patients with CAF. ConclusionsOur study revealed differing prevalence and types of CAF from those reported using coronary angiography and little impact of CAF on hemodynamics. Color Doppler in TTE did not readily depict abnormal flow that might suggest the presence of a fistula, but cardiac CT allowed noninvasive and comprehensive assessment of CAF. Thus, we believe the acquisition of cardiac CT is necessary to establish the cause of continuous murmur that is not identified with TTE.

Coronary artery fistula in adults: evaluation with dual-source CT coronary angiography.

To evaluate the clinical value of dual-source CT (DSCT) coronary angiography in the diagnosis of coronary artery fistula (CAF) in adults. A large cohort of 17,548 patients, who underwent DSCT coronary angiography in our hospital between January 2008 and October 2013, were retrospectively reviewed for CAF. The origin, course and drainage site of CAF and coexisting abnormalities were analysed. The conventional angiography results, treatments and follow-up DSCT images were also evaluated. A total of 33 CAFs from 17,548 patients were detected. The incidence of CAF was 0.19% by DSCT. CAF originating from the left coronary artery (LCA) was found in 14 (42.4%) patients, from right coronary artery (RCA) in 4 (12.1%) cases and from both LCA and RCA in 15 (45.5%) patients. The pulmonary artery was the most common site of drainage (28/33, 84.8%). 8 of the 33 (24.2%) cases were associated with aneurysms. Six cases were associated with coronary artery atherosclerosis. Four patients underwent conventional angiography. Coronary-pulmonary artery fistula in adults was found more often than in previous studies. CAF commonly originates from LCA or both LCA and RCA in adults. DSCT is a robust tool for investigating the origin, course and drainage site of CAF and coexistent abnormalities. A large adult patient cohort who underwent DSCT angiography was reviewed to assess CAFs. Coronary-pulmonary artery fistula in adults was found more often than in previous studies. CAF was observed to originate from the LCA or both coronary arteries in adults. DSCT could clearly depict the fistula origin, course, drainage site and coexisting abnormalities. Conventional angiography results, treatments and follow-up DSCT images were analysed.

Diagnostic and therapeutic approach of congenital solitary coronary artery fistulas in adults: Dutch case series and review of literature

Coronary artery fistulas (CAFs) are infrequent anomalies, coincidentally detected during coronary angiography (CAG). To elucidate the currently used diagnostic imaging modalities and applied therapeutic approaches. Five Dutch patients were found to have CAFs. A total of 170 reviewed subjects were subdivided into two comparable groups of 85 each, treated with either percutaneous 'therapeutic' embolisation (PTE group) or surgical ligation (SL group). In our series, the fistulas were visualised with several diagnostic imaging tests using echocardiography, multidetector computed tomography, and CAG. Four fistulas were unilateral and one was bilateral; five originated from the left and one originated from the right coronary artery. Among the reviewed subjects, high success rates were found in both treatment groups (SL: 97% and PTE: 93%). Associated congenital or acquired cardiovascular disorders were frequently present in the SL group (23%). Bilateral fistulas were present in 11% of the SL group versus 1% of the PTE group. The fistula was ligated surgically in one and abolished percutaneously in another. Medical treatment including metoprolol was conducted in two, and watchful waiting follow-up was performed in one. Several diagnostic imaging techniques are available for assessment of the anatomical and functional characteristics of CAFs.

Current characteristics of congenital coronary artery fistulas in adults: A decade of global experience

To describe the characteristics of coronary artery fistulas (CAFs) in adults, including donor vessels and whether termination was cameral or vascular. A PubMed search was performed for articles between 2000 and 2010 to describe the current characteristics of congenital CAFs in adults. A group of 304 adults was collected. Clinical data, presentations, diagnostic modalities, angiographic fistula findings and treatment strategies were gathered and analyzed. With regard to CAF origin, the subjects were tabulated into unilateral, bilateral or multilateral fistulas and compared. The group was stratified into two major subsets according to the mode of termination; coronary-cameral fistulas (CCFs) and coronary-vascular fistulas (CVFs). A comparison was made between the two subsets. Fistula-related major complications [aneurysm formation, infective endocarditis (IE), myocardial infarction (MI), rupture, pericardial effusion (PE) and tamponade] were described. Coronary artery-ventricular multiple micro-fistulas and acquired CAFs were excluded as well as anomalous origin of the coronary arteries from the pulmonary artery (PA). A total of 304 adult subjects (47% male) with congenital CAFs were included. The mean age was 51.4 years (range, 18-86 years), with 20% older than 65 years of age. Dyspnea (31%), chest pain (23%) and angina pectoris (21%) were the prevalent clinical presentations. Continuous cardiac murmur was heard in 82% of the subjects. Of the applied diagnostic modalities, chest X-ray showed an abnormal shadow in 4% of the subjects. The cornerstone in establishing the diagnosis was echocardiography (68%), and conventional contrast coronary angiography (97%). However, multi-slice detector computed tomography was performed in 16%. The unilateral fistula originated from the left in 69% and from the right coronary artery in 31% of the subjects. Most patients (80%) had unilateral fistulas, 18% presented with bilateral fistulas and 2% with multilateral fistulas. Termination into the PA was reported in unilateral (44%), bilateral (73%) and multilateral (75%) fistulas. Fistulas with multiple origins (bilateral and multilateral) terminated more frequently into the PA (29%) than into other sites (10.6%) (P = 0.000). Aneurysmal formation was found in 14% of all subjects. Spontaneous rupture, PE and tamponade were reported in 2% of all subjects. In CCFs, the mean age was 46.2 years whereas in CVFs mean age was 55.6 years (P = 0.003). IE (4%) was exclusively associated with CCFs, while MI (2%) was only found in subjects with CVFs. Surgical ligation was frequently chosen for unilateral (57%), bilateral (51%) and multilateral fistulas (66%), but percutaneous therapeutic embolization (PTE) was increasingly reported (23%, 17% and 17%, respectively). Congenital CAFs are currently detected in elderly patients. Bilateral fistulas are more frequently reported and PTE is more frequently applied as a therapeutic strategy in adults.

Complex coronary artery fistulas in adults: evaluation with multidetector computed tomography

Coronary artery fistulas (CAFs) are rare congenital or acquired abnormalities that have anomalous terminations of the coronary arteries. Although many patients with CAFs are asymptomatic, they can display various clinical features associated with ischemic heart disease or heart failure. Making an early diagnosis is important for the proper management and prevention of late symptoms and complications. Conventional coronary angiography and cardiac CT have been commonly performed to diagnose CAFs, but multi-detector computed tomography (MDCT) is now being widely applied for diagnosing cardiovascular anomalies, and the number of incidentally detected CAFs on MDCT has been increasing. Therefore, we have to be familiar with the image findings of CAFs, and especially the image findings of MDCT for making the correct diagnosis of CAFs. In this article, we illustrate the MDCT findings of various types of CAFs in adults and we review the pathophysiology and clinical features of CAFs.

Congenital coronary artery fistulas in adults: concomitant pathologies and treatment

Coronary artery fistula is a rare congenital malformation. Complications such as intracardiac shunts, endocarditis, myocardial infarction, aneurysm and sudden death can be observed. The purpose of this article is to present our experience with concomitant cardiac pathologies and discuss various therapeutic approaches including surgical and percutaneous intervention. During 18,272 diagnostic cardiac catheterizations, coronary artery fistulas were identified incidentally in 10 patients (0.05%). There were 3 female and 7 male patients. The patients' ages ranged from 42 to 76 years. All patients with coronary artery fistula were preoperatively in New York Heart Association functional class and Canadian Cardiovascular Society class II or III. In addition to coronary artery fistula, coronary artery disease was detected in 4 patients (40%), a ventricular septal defect and an aneurysm of the sinuses of Valsalvae with aortic regurgitation in one patient (10%) and an anomalous origin of the LAD from the pulmonary trunk in one patient (10%) during cardiac catheterization. Four (40%) of the total of 10 patients had only coronary artery fistula. Surgical closure of the coronary artery fistula was performed in 7 patients (70%). An interventional fistula closure with a coil device was confirmed by cardiac catheterization in another 3 patients (30%). One patient of the latter group showed a small residual shunt from the LAD to the pulmonary trunk. No death or long-term morbidities could be observed. Coronary artery fistulas are incidentally diagnosed during coronary artery angiographies in adults and should be closed to prevent complications.

Feasibility of Cardiovascular Magnetic Resonance of Angiographically Diagnosed Congenital Solitary Coronary Artery Fistulas in Adults

To evaluate the use of cardiovascular magnetic resonance (CMR) to visualize angiographically-detected congenital coronary artery fistulas in adults. CMR techniques were used to study 13 patients, recruited from the Dutch Registry, with previously angiographically diagnosed fistulas. Coronary fistulas were detected in 10 of 13 (77%) patients by CMR and, retrospectively, in two (92%) more. In 93% of these, it was possible to determine the origin and the outflow site of the fistulas. Cardiovascular magnetic resonance allowed demonstration of dilatation of the fistula-related coronary artery in all cases. Tortuosity of fistulas was detected in all visualized patients. Uni-or bilaterality of fistulas as seen on CAG was proven on CMR in all patients. Flow measurement could be performed in 8 patients. A fairly good correlation (r = 0.72) was found between angiographic (mean 6.2 mm, range 1-16) and cardiovascular magnetic resonance (mean 6.3 mm, range 3-15) measured fistulous diameters. Cardiovascular magnetic resonance of congenital fistulas with clinical significant shunting is feasible and can provide additional physiological data complementary to the findings of conventional coronary angiography.

Successful percutaneous closure of multiple coronary artery fistulas with coils embolization in two adults

Fistulas between coronary arteries and cardiac cavities or other vascular structures are uncommon findings usually detected early in life. We describe two cases of late transcatheter occlusion of a double coronary artery fistula in adults complaining of incremental dyspnoea.

Solitary Coronary Artery Fistulas: A Congenital Anomaly in Children and Adults. A Contemporary Review

Congenital solitary coronary artery fistulas (CAFs) in adults are uncommon anomalies, which by themselves may resemble the whole spectrum of cardiac presentations from asymptomatic behavior to life-threatening and catastrophic events with syncope or shock and even sudden death. It may take decades to collect a reasonable series of patients in adults and children. From the literature between 1993 and 2004, 236 patients with CAFs were considered for evaluation. The present review is intended to assist cardiologists who are unfamiliar with congenital CAFs in adults by suggesting clues for decision making regarding diagnosis and management. Dyspnea and chest pain represented a frequent 91/128 (71%) clinical symptom in CAFs in adults while in the pediatric age group the majority were silent 105/133 (79%) and dyspnea and chest pain accounted for only 8% of the symptoms. The diagnostic modalities were mainly cardiac catheterization and coronary angiography. On the other hand, in the pediatric patients, echocardiography and coronary angiography mainly guided the diagnosis. Regarding treatment strategy in the reviewed subjects, percutaneous transluminal embolization was performed in 18% of the pediatric and in only 5% of the adult subjects. Surgical ligation (46% vs. 38%) and conservative medical strategies (36% vs. 24%) were reported in both pediatric and adult groups. Presentations of CAFs vary considerably in both groups. These differences include the diagnostic modalities, spontaneous closure, spontaneous rupture, and management. From this review, it seemed that--but it may be biased--surgical ligation remains the major mainstay for closure of CAFs in adult and pediatric populations. Recommendations are necessary for antibiotic prophylaxis and antiplatelet and/or anticoagulant therapy for prevention of endocarditis and thrombotic events in patients with CAFs associated with coronary artery dilatation or aneurysmal formation of the fistulous tract.

Dutch survey of congenital coronary artery fistulas in adults: Coronary artery-left ventricular multiple micro-fistulas: Multi-center observational survey in the Netherlands

Background Congenital coronary artery-left ventricular multiple micro-fistulas (CA-LVMMFs) in adults are rare anomalies. They may cause angina pectoris and myocardial infarction in association with normal coronary arteries. Methods and results From the medical databases of a Dutch Survey of coronary artery fistulas in adult cardiology population (30,829 patients), we identified 20 patients with CA-LVMMFs out of 71 fistula-subjects between 1996 and 2003. Clinical files and individual coronary angiograms were reviewed and analysed. There were 13 females and 7 males with a mean age of 67.3 years (range 49–82). The main presenting symptoms were angina pectoris and dyspnea in 70% of the patients. The ECG showed pathologic changes in 75%. Exercise tolerance test and 201-thallium stress scintigraphy were positive for myocardial ischemia in 29% and 50%, respectively of the tested patients. In the absence of significant atherosclerotic coronary artery disease, ipsilateral to the fistulas, myocardial infarction was documented in 15% of the patients. Chest X-ray revealed cardiomegaly in 38% of the patients. Congestive heart failure was documented in 10% of the patients. Uni-, bi- and multilateral fistulas were present in 50%, 45% and 5%, respectively. The origin was the LCA in 71% and the RCA in 29% of the fistulas. The majority (97%) originated from the mid or distal segments of the coronary vessels. Among those patients, the coronary arterial tree had single, dual, and triple vessel disease in 25%, 15% and 5%, respectively. Angiographic anatomy precludes surgical intervention; they were all followed by conservative medical management. Conclusions Coronary artery-left ventricular multiple micro-fistulas are found more often in female patients. Furthermore, they originated from the distal segment of the coronary arteries. Coronary artery-left ventricular multiple micro-fistulas, in the presence of normal coronary arterial tree, may often lead to angina pectoris and coronary insufficiency.

Dutch survey of coronary artery fistulas in adults: Congenital solitary fistulas

Aims Congenital coronary artery fistulas are frequently identified in adult and pediatric populations and they have been associated with various clinical and morphological features. The purpose of this study was to define the clinical and coronary angiographic morphological characteristics of adult patients with congenital solitary CAFs in the Dutch Registry. Methods and results Fifty-one patients with angiographically documented CAFs were reviewed for clinical evaluation, used non-invasive and invasive diagnostic tools and treatment modalities. Unilateral CAFs were predominant (80%) and 84% of the patients were symptomatic. The most common presenting symptom was angina pectoris (57%). Angina pectoris was present in a quarter of the patients in the absence of coronary artery disease (CAD). Significant CAD was present in 49% of the patients. Twenty-nine percent of the CAFs showed aneurysmal formation, underlying their potential hazard of rupture. Myocardial infarction occurred in 18% of the patients. In 27% of CAFs multiplicity of the origin was found and nearly all fistulas were tortuous (97%). Treatment modalities were conservative medical in 70%, percutaneous transluminal embolisation in 5% and surgical ligation in 25% of the cases. Multiple micro-fistulas from the coronary arteries to the left ventricle were excluded from the study. Conclusion In this national survey series, congenital solitary CAFs can be presented with typical angina pectoris in the absence of obstructive CAD. Fistula-related coronary artery was infrequently involved in the development of ipsilateral myocardial infarction. Tortuousity and multiplicity of the CAFs may determine, for the individual patient, the choice of the currently available treatment modalities.

Percutaneous Occlusion With Coils of Coronary Artery Fistulas in Adults

Coronary artery fistulas are one of the most common congenital anomalies of the coronary arteries. Most fistulas are small and of no clinical significance, although larger or multiple fistulas can be symptomatic and produce complications. Early percutaneous occlusion is now always recommended, and surgical closure is restricted to use for multiple or large fistulas. Here we report four cases of coronary fistula draining from the coronary arteries to the pulmonary vascular bed, which were treated with percutaneous occlusion by coils.

Congenital coronary artery fistulas in adults: surgical treatment and outcome

Background: Congenital coronary artery fistulas, a subgroup of anomalies of the coronary arteries, are an extremly rare cardiac defect. Most patients are asymptomatic, and if symptoms are presented, they depend on the underlying anatomy. Knowledge of those fistulas is important for prognosis and management. Methods: Thirteen adult patients with congenital coronary fistulas (8 male, 5 female) were operated in our department during the last decade (1990–1999). Mean age was 61.5±10.8 years. Diagnosis was made by coronary angiography, and 15 congenital coronary artery fistulas were found. Results: All patients were symptomatic with clinical symptoms depending on the associated cardiac disorder. Coronary artery fistulas originated from the proximal left descending artery ( n=10), left main stem ( n=3), circumflex artery ( n=1), right coronary artery ( n=1), and drained into the main pulmonary artery ( n=14) and left ventricle ( n=1). Nine fistulas (60%) were interrupted on the outside of the heart, and six fistulas (40%) were closed through the opened pulmonary artery. There was no surgical death and no fistula-related complication. Conclusions: Surgical closure of congenital coronary artery fistulas in adults can be performed with a very low risk, and closure is recommended to prevent complications.

CONGENITAL CORONARY ARTERY FISTULAS IN TURKISH PATIENTS UNDERGOING DIAGNOSTIC CARDIAC ANGIOGRAPHY

SUMMARYA coronary artery fistula is a direct communication between a coronary artery and one of the cardiac chambers or vessels around the heart. The present study was undertaken to define the incidence, clinical findings and angiographic characteristics of congenital coronary artery fistula in Turkish adults who underwent diagnostic cardiac angiography. A consecutive series of 11,350 coronary angiography, performed between January 2000 and December 2001, was retrospectively examined for the presence of coronary artery fistulas. The incidence of congenital coronary artery fistulas was 0.08%. All the patients had chest pain during exertion or at rest. All the fistulas were single and most arose from the proximal left anterior descending coronary artery and drained into the pulmonary artery. All the fistulas were small. Surgical treatment was not indicated. A congenital coronary artery fistula in adults is a distinct though rare entity, variable in its incidence and commonly associated with coronary artery obstructive disease. Diagnosis is mostly incidental during routine coronary angiography.

Coronary artery fistulas in adults: incidence, angiographic characteristics, natural history.

The incidence, angiographic characteristics, and natural history of coronary artery fistulas in patients undergoing diagnostic cardiac catheterization have not been well defined. Of 33,600 patients who had diagnostic cardiac catheterization, 34 (0.1%) had coronary artery fistula. Nineteen fistulas originated from the right, 11 from the left anterior descending, and 4 from the circumflex coronary arteries, respectively. The mean ratio of pulmonary to systemic flow was 1.19 +/- 0.33. Only one patient with coexistent atrial septal defect had a pulmonic to systemic flow ratio > 1.5. Right and left heart pressures, with the exception of three patients in whom left ventricular end-diastolic pressures was > 12 mm Hg, were within normal limits. During a mean follow-up period of 6.3 years (range 2-14 years), there were no complications related to coronary artery fistula. It was concluded that the incidence of coronary artery fistulas detected during diagnostic coronary angiography is very low. Coronary artery fistulas originate predominantly from the right coronary artery and are not associated with hemodynamic abnormalities or other congenital heart diseases. The prognosis of coronary artery fistulas in adults is good.