Case Report
A Giant Left Main Trunk and Left Circumflex Artery‑to‑Right Ventricle Fistula Zhao‑hui Peng, Min Li, Gao Xin1, Gang Sun Department of Medical Imaging, Jinan Military General Hospital, 1Department of Radiology, Children’s Hospital of Jinan, Jinan, Shandong Province, China
ABSTRACT Coronary artery fistula including the left trunk and left circumflex is uncommon. We present a 24‑year‑old male patient with a giant left main trunk and left circumflex artery to right ventricle fistula, which is diagnosed by transthoracic echocardiography and coronary computed tomography angiography. In this paper, the case report is to provide a better understanding of clinical characteristics for this disease.
Key words: Angiography, computed tomography, coronary artery, Fistula How to cite this article: Peng Z, Li M, Xin G, Sun G. A giant left main trunk and left circumflex artery-to-right ventricle fistula. Heart Views 2014;15:51-3. © Gulf Heart Association 2014.
INTRODUCTION
C
oronary artery fistula (CAF) is an unusual coronary artery abnormality, where connection exists between coronary artery and cardiac chamber or another blood vessel. It occurs in 0.3‑0.8% of patients undergoing selective coronary angiography.[1] It predominantly originates from the right coronary artery. The left circumflex coronary artery is seldom involved.[2] CAF originating from the left main trunk and left circumflex artery is very unusual and rarely reported in the literature. We describe a case of giant left main trunk and left circumflex artery fistula to the right ventricle.
CASE REPORT A 24‑year‑old male patient presented with complaints of dyspnea and palpitation during exercise. On physical examination, his blood pressure was 120/80 mmHg and pulse rate was 75 bpm. The heart was rhythmic and chest auscultation revealed a continuous murmur of grade 3/6 at the upper left sternal border. Electrocardiography demonstrated no apparent ST segment and T‑wave abnormalities. Transthoracic echocardiography (TTE) showed enlargement of the left main trunk and left circumflex coronary artery, with a 25‑mm inner diameter, diffusely tortuous dilated and drained into the posterior wall of the Address for correspondence: Dr. Gang Sun,
Department of Medical Imaging, Jinan Military General Hospital, No, 25, Shifan Road, Jinan, Shandong Province, 250 031, China. E‑mail: cjr.sungang@vip. 163.com
51
right ventricle [Figure 1]. Left anterior descending artery, right coronary artery, and major side branches were normal. The left ventricular systolic function was normal with an ejection fraction of 65% and there were no abnormalities in the regional wall motion and cardiac valves. Mild right ventricular hypertrophy and enlargement were detected. Pulmonary artery systolic pressure measured using tricuspid regurgitant jet velocity was 40 mmHg. Laboratory investigations were normal. In order to further evaluate the fistula in more detail, a 320‑slice dynamic volume CT (Aquilion ONE, software release v. 4.3, Toshiba Medical Systems, Japan) angiogram was performed, using 3‑dimensional volume‑rendered (VR) and curved‑plain reconstruction (CPR). It demonstrated a large fistula arising from the left main trunk and left circumflex artery emptying to the right ventricle [Figure 2]. We confirmed the location and course of the fistula. Surgical ligation and transcatheter occlusion operation was recommended. The patient, however, refused any treatment.
DISCUSSION CAF can be congenital or acquired anomaly of vascular communications. Access this article online Quick Response Code:
Website: www.heartviews.org DOI: 10.4103/1995-705X.137501
HEART VIEWS Apr-Jun 14 Issue 2 / Vol 15
Peng, et al.: A giant fistula
Figure 1: Color‑Doppler echocardiography revealed enlarged and tortuous of LM and LCX (white arrows) origin from AO, abnormal
flow from AO passing LM and LCX to RV through a fistula (red arrow). (AO: Aorta, LM: Left main trunk, LCX: Left circumflex artery, LV: Left ventricle, RV: Right ventricle, RA: Righe atrium, LA: Left atrium)
Figure 2: Contrast‑enhanced CT coronary angiogram. 3‑dimensional volume‑rendered (VR) and curved‑plain reconstruction (CPR)
shows origin and course of the fistula. The vessel runs from the left main trunk and left circumflex coronary artery and drained into the posterior wall of the right ventricle through a fistula (red arrow). (AO: Aorta, LM: Left main trunk, LCX: Left circumflex artery, LV: Left ventricle, RV: Right ventricle)
Congenital CAF is caused by a cardiovascular abnormality in embryo period, which accounts for 0.27‑0.40% of all congenital cardiac defects.[3] Acquired CAF has been described after surgical procedures, endomyocardial biopsy, trauma, inflammation, atherosclerosis, and collagen vascular disease.[4] The prevalence of right CAF is higher than that of left coronary artery. Low pressure structures are the most common sites of CAF drainage. CAF usually drains into the right chamber, pulmonary artery, pulmonary veins, superior vena cava, inferior vena cava, and coronary sinus.[5] Most CAF patients are usually asymptomatic and are found incidentally during angiographic evaluation HEART VIEWS Apr-Jun 14 Issue 2 / Vol 15
for other cardiac diseases. Clinical symptoms of patients with CAF are dependent on the size of fistula and the pressure of its terminal chamber. In our patient, the giant CAF increases the volume load of the right heart chambers and the pulmonary artery. If the shunt of CAF is significant, steal blood phenomenon may occur and cause myocardial ischemia or infarction, which increases risk of infective endocarditis, accelerates atherosclerosis, and even heart failure.[6] Generally, TTE is an important primary non‑invasive tool for diagnosis of coronary artery abnormality and confirmed by coronary angiography. With the cardiac CT technological improvement in recent years, 52
Peng, et al.: A giant fistula
particularly in temporal/spatial resolution and reduced radiation dose, coronary computed tomography angiography (CCTA) has been a relatively new imaging modality and non‑invasive method for assessment of coronary artery disease.[7] CCTA not only precisely demonstrate the origin, course, and drainage site of the fistula, but also provides surgical plan for treatment. However, coronary angiography still remains the gold standard for diagnosing coronary anomalies. Current treatment options include surgical ligation and percutaneous embolization. It is suggested that CAF should be treated as soon as possible to avoid the potential risk of complications, no matter whether clinical symptom exists or not. In our case, the patient refused treatment, because of a terrible fear of operation. He experienced no serious cardiac events over half a year of follow‑up. In conclusion, the giant left main trunk and left circumflex artery fistula to the right ventricle are rarely seen. CCTA is a very useful tool in the diagnosis of CAF. The optimal treatment for CAF is surgical ligation and percutaneous embolization.
2.
3.
4.
5.
6.
7.
coronary‑to‑pulmonary artery fistula. Turk Kardiyol Dern Ars 2008;36:476‑8. Bruhin R, Stock UA, Breuer M, Wahlers T. Successful in situ repair of a symptomatic left main coronary artery aneurysm by a saphenous vein graft.Interactive CardioVascular and Thoracic Surgery. Interact Cardiovasc Thorac Surg 2004;3:434‑6. Sunder KR, Balakrishnan KG, Tharakan JA, Titus T, Pillai VR, Francis B, et al. Coronary artery fistula in children and adults: A review of 25 cases with long‑term observations. Int J Cardiol 1997;58:47‑53. Okamura T, Nagashima M, Yamada Y, Hiramatsu T, Yamazaki K. Effective long‑term surgical management of congenital coronary artery fistulas. Tohoku J Exp Med 2011;223:205‑9. Schumacher G, Roithmaier A, Lorenz HP, Meisner H, Sauer U, Müller KD, et al. Congenital coronary artery fistula in infancy and childhood: Diagnostic and therapeutic aspects. Thorac Cardiovasc Surg 1997;45:287‑94. Qawoq H, Krecki R, Lipiec P, Krzemińska‑Pakuła M, Kasprzak JD. A coronary fistula diagnosed in the eighth decade of life: The utility of non‑invasive methods in the selection of treatment approach. Cardiol J 2010;17:299‑302. Early SA, Meany TB, Fenlon HM, Hurley J. Coronary artery fistula; coronary computed topography – the diagnostic modality of choice. J Cardiothorac Surg 2008;5;3:41.
REFERENCES 1.
Kaçmaz F, Maden O, Erbay AR, Ilkay E. A very rare cause of continuous murmur and coronary ischemia: High‑flow
Source of Support: Nil, Conflict of Interest: None declared.
Author Help: Reference checking facility The manuscript system (www.journalonweb.com) allows the authors to check and verify the accuracy and style of references. The tool checks the references with PubMed as per a predefined style. Authors are encouraged to use this facility, before submitting articles to the journal. • The style as well as bibliographic elements should be 100% accurate, to help get the references verified from the system. Even a single spelling error or addition of issue number/month of publication will lead to an error when verifying the reference. • Example of a correct style Sheahan P, O’leary G, Lee G, Fitzgibbon J. Cystic cervical metastases: Incidence and diagnosis using fine needle aspiration biopsy. Otolaryngol Head Neck Surg 2002;127:294-8. • Only the references from journals indexed in PubMed will be checked. • Enter each reference in new line, without a serial number. • Add up to a maximum of 15 references at a time. • If the reference is correct for its bibliographic elements and punctuations, it will be shown as CORRECT and a link to the correct article in PubMed will be given. • If any of the bibliographic elements are missing, incorrect or extra (such as issue number), it will be shown as INCORRECT and link to possible articles in PubMed will be given.
53
HEART VIEWS Apr-Jun 14 Issue 2 / Vol 15
Copyright of Heart Views is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
A Giant Left Main Trunk and Left Circumflex Artery‑to‑Right Ventricle Fistula Zhao‑hui Peng, Min Li, Gao Xin1, Gang Sun Department of Medical Imaging, Jinan Military General Hospital, 1Department of Radiology, Children’s Hospital of Jinan, Jinan, Shandong Province, China
ABSTRACT Coronary artery fistula including the left trunk and left circumflex is uncommon. We present a 24‑year‑old male patient with a giant left main trunk and left circumflex artery to right ventricle fistula, which is diagnosed by transthoracic echocardiography and coronary computed tomography angiography. In this paper, the case report is to provide a better understanding of clinical characteristics for this disease.
Key words: Angiography, computed tomography, coronary artery, Fistula How to cite this article: Peng Z, Li M, Xin G, Sun G. A giant left main trunk and left circumflex artery-to-right ventricle fistula. Heart Views 2014;15:51-3. © Gulf Heart Association 2014.
INTRODUCTION
C
oronary artery fistula (CAF) is an unusual coronary artery abnormality, where connection exists between coronary artery and cardiac chamber or another blood vessel. It occurs in 0.3‑0.8% of patients undergoing selective coronary angiography.[1] It predominantly originates from the right coronary artery. The left circumflex coronary artery is seldom involved.[2] CAF originating from the left main trunk and left circumflex artery is very unusual and rarely reported in the literature. We describe a case of giant left main trunk and left circumflex artery fistula to the right ventricle.
CASE REPORT A 24‑year‑old male patient presented with complaints of dyspnea and palpitation during exercise. On physical examination, his blood pressure was 120/80 mmHg and pulse rate was 75 bpm. The heart was rhythmic and chest auscultation revealed a continuous murmur of grade 3/6 at the upper left sternal border. Electrocardiography demonstrated no apparent ST segment and T‑wave abnormalities. Transthoracic echocardiography (TTE) showed enlargement of the left main trunk and left circumflex coronary artery, with a 25‑mm inner diameter, diffusely tortuous dilated and drained into the posterior wall of the Address for correspondence: Dr. Gang Sun,
Department of Medical Imaging, Jinan Military General Hospital, No, 25, Shifan Road, Jinan, Shandong Province, 250 031, China. E‑mail: cjr.sungang@vip. 163.com
51
right ventricle [Figure 1]. Left anterior descending artery, right coronary artery, and major side branches were normal. The left ventricular systolic function was normal with an ejection fraction of 65% and there were no abnormalities in the regional wall motion and cardiac valves. Mild right ventricular hypertrophy and enlargement were detected. Pulmonary artery systolic pressure measured using tricuspid regurgitant jet velocity was 40 mmHg. Laboratory investigations were normal. In order to further evaluate the fistula in more detail, a 320‑slice dynamic volume CT (Aquilion ONE, software release v. 4.3, Toshiba Medical Systems, Japan) angiogram was performed, using 3‑dimensional volume‑rendered (VR) and curved‑plain reconstruction (CPR). It demonstrated a large fistula arising from the left main trunk and left circumflex artery emptying to the right ventricle [Figure 2]. We confirmed the location and course of the fistula. Surgical ligation and transcatheter occlusion operation was recommended. The patient, however, refused any treatment.
DISCUSSION CAF can be congenital or acquired anomaly of vascular communications. Access this article online Quick Response Code:
Website: www.heartviews.org DOI: 10.4103/1995-705X.137501
HEART VIEWS Apr-Jun 14 Issue 2 / Vol 15
Peng, et al.: A giant fistula
Figure 1: Color‑Doppler echocardiography revealed enlarged and tortuous of LM and LCX (white arrows) origin from AO, abnormal
flow from AO passing LM and LCX to RV through a fistula (red arrow). (AO: Aorta, LM: Left main trunk, LCX: Left circumflex artery, LV: Left ventricle, RV: Right ventricle, RA: Righe atrium, LA: Left atrium)
Figure 2: Contrast‑enhanced CT coronary angiogram. 3‑dimensional volume‑rendered (VR) and curved‑plain reconstruction (CPR)
shows origin and course of the fistula. The vessel runs from the left main trunk and left circumflex coronary artery and drained into the posterior wall of the right ventricle through a fistula (red arrow). (AO: Aorta, LM: Left main trunk, LCX: Left circumflex artery, LV: Left ventricle, RV: Right ventricle)
Congenital CAF is caused by a cardiovascular abnormality in embryo period, which accounts for 0.27‑0.40% of all congenital cardiac defects.[3] Acquired CAF has been described after surgical procedures, endomyocardial biopsy, trauma, inflammation, atherosclerosis, and collagen vascular disease.[4] The prevalence of right CAF is higher than that of left coronary artery. Low pressure structures are the most common sites of CAF drainage. CAF usually drains into the right chamber, pulmonary artery, pulmonary veins, superior vena cava, inferior vena cava, and coronary sinus.[5] Most CAF patients are usually asymptomatic and are found incidentally during angiographic evaluation HEART VIEWS Apr-Jun 14 Issue 2 / Vol 15
for other cardiac diseases. Clinical symptoms of patients with CAF are dependent on the size of fistula and the pressure of its terminal chamber. In our patient, the giant CAF increases the volume load of the right heart chambers and the pulmonary artery. If the shunt of CAF is significant, steal blood phenomenon may occur and cause myocardial ischemia or infarction, which increases risk of infective endocarditis, accelerates atherosclerosis, and even heart failure.[6] Generally, TTE is an important primary non‑invasive tool for diagnosis of coronary artery abnormality and confirmed by coronary angiography. With the cardiac CT technological improvement in recent years, 52
Peng, et al.: A giant fistula
particularly in temporal/spatial resolution and reduced radiation dose, coronary computed tomography angiography (CCTA) has been a relatively new imaging modality and non‑invasive method for assessment of coronary artery disease.[7] CCTA not only precisely demonstrate the origin, course, and drainage site of the fistula, but also provides surgical plan for treatment. However, coronary angiography still remains the gold standard for diagnosing coronary anomalies. Current treatment options include surgical ligation and percutaneous embolization. It is suggested that CAF should be treated as soon as possible to avoid the potential risk of complications, no matter whether clinical symptom exists or not. In our case, the patient refused treatment, because of a terrible fear of operation. He experienced no serious cardiac events over half a year of follow‑up. In conclusion, the giant left main trunk and left circumflex artery fistula to the right ventricle are rarely seen. CCTA is a very useful tool in the diagnosis of CAF. The optimal treatment for CAF is surgical ligation and percutaneous embolization.
2.
3.
4.
5.
6.
7.
coronary‑to‑pulmonary artery fistula. Turk Kardiyol Dern Ars 2008;36:476‑8. Bruhin R, Stock UA, Breuer M, Wahlers T. Successful in situ repair of a symptomatic left main coronary artery aneurysm by a saphenous vein graft.Interactive CardioVascular and Thoracic Surgery. Interact Cardiovasc Thorac Surg 2004;3:434‑6. Sunder KR, Balakrishnan KG, Tharakan JA, Titus T, Pillai VR, Francis B, et al. Coronary artery fistula in children and adults: A review of 25 cases with long‑term observations. Int J Cardiol 1997;58:47‑53. Okamura T, Nagashima M, Yamada Y, Hiramatsu T, Yamazaki K. Effective long‑term surgical management of congenital coronary artery fistulas. Tohoku J Exp Med 2011;223:205‑9. Schumacher G, Roithmaier A, Lorenz HP, Meisner H, Sauer U, Müller KD, et al. Congenital coronary artery fistula in infancy and childhood: Diagnostic and therapeutic aspects. Thorac Cardiovasc Surg 1997;45:287‑94. Qawoq H, Krecki R, Lipiec P, Krzemińska‑Pakuła M, Kasprzak JD. A coronary fistula diagnosed in the eighth decade of life: The utility of non‑invasive methods in the selection of treatment approach. Cardiol J 2010;17:299‑302. Early SA, Meany TB, Fenlon HM, Hurley J. Coronary artery fistula; coronary computed topography – the diagnostic modality of choice. J Cardiothorac Surg 2008;5;3:41.
REFERENCES 1.
Kaçmaz F, Maden O, Erbay AR, Ilkay E. A very rare cause of continuous murmur and coronary ischemia: High‑flow
Source of Support: Nil, Conflict of Interest: None declared.
Author Help: Reference checking facility The manuscript system (www.journalonweb.com) allows the authors to check and verify the accuracy and style of references. The tool checks the references with PubMed as per a predefined style. Authors are encouraged to use this facility, before submitting articles to the journal. • The style as well as bibliographic elements should be 100% accurate, to help get the references verified from the system. Even a single spelling error or addition of issue number/month of publication will lead to an error when verifying the reference. • Example of a correct style Sheahan P, O’leary G, Lee G, Fitzgibbon J. Cystic cervical metastases: Incidence and diagnosis using fine needle aspiration biopsy. Otolaryngol Head Neck Surg 2002;127:294-8. • Only the references from journals indexed in PubMed will be checked. • Enter each reference in new line, without a serial number. • Add up to a maximum of 15 references at a time. • If the reference is correct for its bibliographic elements and punctuations, it will be shown as CORRECT and a link to the correct article in PubMed will be given. • If any of the bibliographic elements are missing, incorrect or extra (such as issue number), it will be shown as INCORRECT and link to possible articles in PubMed will be given.
53
HEART VIEWS Apr-Jun 14 Issue 2 / Vol 15
Copyright of Heart Views is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
