Author + information
- Received March 11, 2013
- Accepted March 15, 2013
- Published online October 1, 2013.
- Todd L. Kiefer, MD∗∗ (, )
- John Vavalle, MD∗,
- Sharif Halim, MD∗,
- Prashant Kaul, MD†,
- J. Larry Klein, MD†,
- Lynne H. Hurwitz, MD‡,
- Jeffrey G. Gaca, MD§ and
- J. Kevin Harrison, MD∗
- ∗Division of Cardiology, Duke University Medical Center, Durham, North Carolina
- †Division of Cardiology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
- ‡Division of Radiology, Duke University Medical Center, Durham, North Carolina
- §Division of Cardiac Surgery, Duke University Medical Center, Durham, North Carolina
- ↵∗Reprint requests and correspondence:
Dr. Todd Kiefer, Box 3126 DUMC, Duke University Medical Center, 2301 Erwin Road, DUMC Box 3126, Durham, North Carolina 27710.
A 33-year-old woman was evaluated for palpitations and a continuous murmur. Echocardiography demonstrated a dilated vascular structure posterior to the aortic root. Coronary angiography revealed a coronary–cameral fistula originating from the left main coronary artery emptying into the right atrium (RA) via a kidney-shaped vascular cistern (Fig. 1, Online Video 1). The left dominant coronary gave rise to the left anterior descending (LAD) and circumflex (LCX) arteries within 10 mm of the left coronary ostium. The pulmonary artery pressure was 60/30 mm Hg, and the Qp/Qs ratio was 1.5.
Because of atrial arrhythmias and the pulmonary hypertension associated with the left-to-right shunt, fistula closure was advised.
Procedural planning employing computed tomographic angiography (CTA) (Fig. 2, Online Video 2), suggested multiple fistula exit sites into the RA; anatomy was confirmed by transesophageal echocardiography. Therefore, retrograde closure was not pursued.
An anterograde approach from the right femoral artery using a telescoping dual guide catheter system was employed. An 8-F extra-backup (XB) 3.5 guide catheter (Cordis, Miami, Florida) was cut to a length that would just reach the left coronary origin. A 7-F Terumo sheath (Terumo Medical, Somerset, New Jersey) applied to the adulterated end afforded hemostasis. A 0.035-inch Terumo Glidewire was advanced into the coronary fistula, coiling the distal wire within the cistern (Fig. 3). Over this guidewire, a 100-cm length, 6-F Judkins right 4.0 (JR4) guide catheter was advanced within the 8-F guide, with the distal tip reaching the entrance of the vascular cistern. Based on the CTA centerline analysis of the diameter (Fig. 4), a 12-mm Amplatzer Vascular Plug II (St. Jude Medical, Plymouth, Minnesota) was deployed via the 6-F guide.
Angiography demonstrated complete cessation of fistula flow (Fig. 5, Online Video 3) and improved angiographic filling of the LAD and LCX coronary arteries. The patient did well, was discharged the following morning, and was well at the 30-day post-operative re-evaluation.
Large coronary fistulae are uncommon, observed in 225 of 126,595 consecutive angiograms (1). The associated shunt may lead to volume loading, arrhythmias, pulmonary hypertension, heart failure, and/or coronary steal.
Treatment options include open surgical and catheterization-based fistula closure. The latter is associated with good procedural success in selected cases (2). Attention to anatomic detail, procedural planning, and the ability to improvise from standard catheter techniques are important to catheterization-based success. For anterograde closure in particular, it is critical that the operator ensure that fistula closure is distal to the origin of all native coronary branches.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received March 11, 2013.
- Accepted March 15, 2013.
- American College of Cardiology Foundation