Contrast Transesophageal Echocardiographic Demonstration of Coronary Artery Fistula Within Left Atrial Appendage Thrombus in Mitral Stenosis Ping-Ran Lo, MD, Sarah Chua, MD, Morgan Fu, MD, Kou-Ho Yeh, MD, Shunei Kyo, MD, and Jui-Sung Hung, MD, FACC, Kaohsiung, Taiwan, Republic of China, and Saitama, Japan
Coronary neovascularization and fistula formation arising from the left circumflex artery demonstrated by coronary angiography is a specific sign for the presence of left atrial appendage thrombus in patients with mitral stenosis. However, the fistula drainage site in the left atrium in relation to the thrombus cannot be ascertained by the angiographic method. We performed transesophageal echocardiography simultaneously with coronary angiography in five patients with severe mitral stenosis and left atrial appendage thrombus. The angiography showed coronary neovascularization and fistula arising from the left circumflex artery in three patients. In these three patients, the transesophageal echocardiography confirmed the presence of a coronary fistula by identifying contrast exuding from the surface of the thrombus. Thus we have shown for the first time the usefulness of contrast transesophageal echocardiography in imaging the exact drainage site of coronary artery fistula from left atrial appendage thrombus. (JAM Soc ECHOCARDIOGR 1992;5:471-4.)
Although transthoracic contrast echocardiography is an established method for demonstration of congenital intracardiac and extracardiac shunts, there have been only two previous reports using transthoracic contrast echocardiography for defining the drainage site of a congenital coronary artery fistula. 1•2 Our study, in patients with rheumatic mitral stenosis, has shown that an acquired coronary neovascularization and fistula arising from the left circumflex artery is a specific sign for the presence of left atrial appendage thrombus. 3 However, the fistula drainage site in the left atrium in relation to the left atrial appendage thrombus cannot be ascertained by the angiographic method. Because transthoracic echocardiography is not sensitive for demonstration of left atrial appendage thrombus,4 we used transesophageal echocardiography (TEE) simultaneously with
From the Section of Cardiology, Kaohsiung Medical Center, Chang Gung Memorial Hospital, and the First Department of Surgery, Saitama Medical College. Reprint requests: Jui-Sung Hung, MD, FACC, Chang Gung Memorial Hospital, 199 Tung Hwa North Road, Taipei 105, Taiwan, Republic of China. 27/l/39479
coronary angiography to elucidate the exact drainage site of the fistula in patients with severe rheumatic mitral stenosis and left atrial appendage thrombus.
CASE STUDIES
The study population consisted of five patients with severe mitral stenosis and left atrial appendage thrombus detected by TEE. They were two men and three women with an age range from 49 to 65 years. All patients were in atrial fibrillation. After fasting overnight and giving informed consent, the patients underwent diagnostic cardiac catheterization that confirmed the presence of severe mitral stenosis. Mter placement of a newly developed, more flexible 5 MHz biplane transesophageal echo system (Aloka SSD 870-CFM, Tokyo, Japan), selective coronary angiography was then performed with standard Judkin's technique. None of the patients received parenteral sedation. An anticholinergic agent, neutral butyl scopolamine 20 mg, was given intramuscularly to decrease elevated secretions. Local anesthesia of the hypopharynx was achieved by topical spraying of aerosolized 8% lidocaine until maximal gag suppres471
472
Journal of the American Society of Echocardiography
Lo et al.
TEE
Figure 1 Coronary angiogram in the right anterior oblique view showing neovascularization (white arrow head) arising from the left circumflex artery with fistula formation manifested by a dense mass stain (white arrows) and spreading of contrast medium into the left atrial cavity (wide hollow arrow). LCX, Left circumflex artery; LAD, left anterior descending artery; TEE, transesophageal biplane transducers.
sion was achieved. Intermittent suctions of secretion were performed as needed. The patients were turned to the supine position after the transesophageal probe was inserted while patient was in the left lateral decubitus position. TEE showed a left atrial appendage thrombus and left atrial spontaneous echo in all five patients. The coronary angiography showed the presence of neovascularization and fistula formation arising from the left circumflex artery (Figure 1) in three patients. In these three patients, TEE confirmed the presence of a coronary fistula by identifYing contrast exuding from the surface of the thrombus (Figure 2). Being larger and more dense, the contrast echo particles were distinctly different from the preexisting spontaneous echo in the left atrium. In the other two patients, a coronary fistula was not demonstrated by either TEE or angiography.
DISCUSSION
In 1975, Standen, 5 using selective coronary angiography, noted "tumor vascularity'' with abnormal
vessels ansmg from the left circumflex artery and leading to the left atrium in a patient with severe mitral stenosis and left atrial thrombus. He suggested that the fistula formation in the left atrium results from partial necrosis of the organizing thrombus with ulcerated surface, which allows coronary blood to escape into the left atrial cavity. Microscopic examination of left atrial thrombi in patients with coronary neovascularization and fistula formation showed vascular channels with endothelial linings within the thrombi, but it failed to identifY the drainage site of the fistula. 5 Our previous study has shown that angiographic findings of coronary neovascularization and fistula formation are a specific sign for the presence of left atrial appendage thrombus in patients with rheumatic mitral stenosis. 3 However, the direct proof that the angiographic neovascularity and fistula are truly within a thrombus is still lacking. In this study TEE was performed simultaneously with coronary angiography. The angiographic stain of opacified blood was found to represent neovascularity within the left atrial thrombus, and the jets of blood squirting into the left atrium seen on
Volume 5 Number 5 September-October 1992
Contrast TEE of coronary artery fistula
4 73
Figure 2 Top, Control TEE (in transverse plane) shows a left atrial appendage thrombus. Bottom, Mter selective injection of contrast medium in the left coronary artery, the echocardiogram shows dense contrast echo (arrows) emerging from a single drainage site (arrcnv head) on the surface of the thrombus into the left atrium.
coronary angiography were shown to be a fistula with its drainage site on the surface of the thrombus. In this study we reaffirmed the usefulness of contrast echocardiography as an imaging modality in the visualization of the exact drainage sites of coronary artery fistula as previously shown by Reeder et al. 1 and Cooper et al. 2 in cases of congenital coronary artery fistulae. In our patients with severe mitral stenosis and left atrial appendage thrombus, the drainage site of an acquired coronary artery fistula arising from the left circumflex artery could only be elucidated by simultaneous contrast TEE and coronary
angiography. The reason for this is that transthoracic echocardiography is not suited for imaging the left atrial appendage area. With the advent of TEE, the left atrial appendage could be visualized relatively easily. The close proximity of the esophagus to the left atrium permits the use of a high-frequency (5 MHz) transducer and evaluation of various crosssectional planes of the left atrium through proper adjustment of the position of the transducer. Therefore, we have demonstrated for the first time the usefulness of contrast TEE in imaging the exact drainage site of a coronary artery fistula from left atrial appendage thrombus.
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Lo et al.
REFERENCES l. Reeder GS, Tajik AJ, Smith HC. Visualization of coronary artery fistula by two-dimensional echocardiography. Mayo Clin Proc 1980;55:185-9. 2. Cooper MJ, Bernstein D, Silverman NH. Recognition of left coronary artery fistula to the left and right ventricle by contrast echocardiography. J Am Coli Cardiol 1985;6:923-6. 3. Fu M, Hung JS, Lee CB, et al. Coronary neovascularization
Journal of the American Society of Echocardiography
as a specific sign for atrial left appendage thrombus in mitral stenosis. Am J Cardioll991;67:ll58-60. 4. Aschenberg W, Schluter M, Kremer P, Schroder E, Siglow V, Bleifeld W. Transesophageal two-dimensional echocardiography for the detection of left atrial appendage thrombus. J Am Coli Cardiol 1986;7:163-6. 5. Standen JR. "Tumor vascularity'' in left atrial thrombus demonstrated by selective coronary arteriography. Diagnostic Radiology 1975;116:549-50.
Coronary neovascularization and fistula formation arising from the left circumflex artery demonstrated by coronary angiography is a specific sign for the presence of left atrial appendage thrombus in patients with mitral stenosis. However, the fistula drainage site in the left atrium in relation to the thrombus cannot be ascertained by the angiographic method. We performed transesophageal echocardiography simultaneously with coronary angiography in five patients with severe mitral stenosis and left atrial appendage thrombus. The angiography showed coronary neovascularization and fistula arising from the left circumflex artery in three patients. In these three patients, the transesophageal echocardiography confirmed the presence of a coronary fistula by identifying contrast exuding from the surface of the thrombus. Thus we have shown for the first time the usefulness of contrast transesophageal echocardiography in imaging the exact drainage site of coronary artery fistula from left atrial appendage thrombus. (JAM Soc ECHOCARDIOGR 1992;5:471-4.)
Although transthoracic contrast echocardiography is an established method for demonstration of congenital intracardiac and extracardiac shunts, there have been only two previous reports using transthoracic contrast echocardiography for defining the drainage site of a congenital coronary artery fistula. 1•2 Our study, in patients with rheumatic mitral stenosis, has shown that an acquired coronary neovascularization and fistula arising from the left circumflex artery is a specific sign for the presence of left atrial appendage thrombus. 3 However, the fistula drainage site in the left atrium in relation to the left atrial appendage thrombus cannot be ascertained by the angiographic method. Because transthoracic echocardiography is not sensitive for demonstration of left atrial appendage thrombus,4 we used transesophageal echocardiography (TEE) simultaneously with
From the Section of Cardiology, Kaohsiung Medical Center, Chang Gung Memorial Hospital, and the First Department of Surgery, Saitama Medical College. Reprint requests: Jui-Sung Hung, MD, FACC, Chang Gung Memorial Hospital, 199 Tung Hwa North Road, Taipei 105, Taiwan, Republic of China. 27/l/39479
coronary angiography to elucidate the exact drainage site of the fistula in patients with severe rheumatic mitral stenosis and left atrial appendage thrombus.
CASE STUDIES
The study population consisted of five patients with severe mitral stenosis and left atrial appendage thrombus detected by TEE. They were two men and three women with an age range from 49 to 65 years. All patients were in atrial fibrillation. After fasting overnight and giving informed consent, the patients underwent diagnostic cardiac catheterization that confirmed the presence of severe mitral stenosis. Mter placement of a newly developed, more flexible 5 MHz biplane transesophageal echo system (Aloka SSD 870-CFM, Tokyo, Japan), selective coronary angiography was then performed with standard Judkin's technique. None of the patients received parenteral sedation. An anticholinergic agent, neutral butyl scopolamine 20 mg, was given intramuscularly to decrease elevated secretions. Local anesthesia of the hypopharynx was achieved by topical spraying of aerosolized 8% lidocaine until maximal gag suppres471
472
Journal of the American Society of Echocardiography
Lo et al.
TEE
Figure 1 Coronary angiogram in the right anterior oblique view showing neovascularization (white arrow head) arising from the left circumflex artery with fistula formation manifested by a dense mass stain (white arrows) and spreading of contrast medium into the left atrial cavity (wide hollow arrow). LCX, Left circumflex artery; LAD, left anterior descending artery; TEE, transesophageal biplane transducers.
sion was achieved. Intermittent suctions of secretion were performed as needed. The patients were turned to the supine position after the transesophageal probe was inserted while patient was in the left lateral decubitus position. TEE showed a left atrial appendage thrombus and left atrial spontaneous echo in all five patients. The coronary angiography showed the presence of neovascularization and fistula formation arising from the left circumflex artery (Figure 1) in three patients. In these three patients, TEE confirmed the presence of a coronary fistula by identifYing contrast exuding from the surface of the thrombus (Figure 2). Being larger and more dense, the contrast echo particles were distinctly different from the preexisting spontaneous echo in the left atrium. In the other two patients, a coronary fistula was not demonstrated by either TEE or angiography.
DISCUSSION
In 1975, Standen, 5 using selective coronary angiography, noted "tumor vascularity'' with abnormal
vessels ansmg from the left circumflex artery and leading to the left atrium in a patient with severe mitral stenosis and left atrial thrombus. He suggested that the fistula formation in the left atrium results from partial necrosis of the organizing thrombus with ulcerated surface, which allows coronary blood to escape into the left atrial cavity. Microscopic examination of left atrial thrombi in patients with coronary neovascularization and fistula formation showed vascular channels with endothelial linings within the thrombi, but it failed to identifY the drainage site of the fistula. 5 Our previous study has shown that angiographic findings of coronary neovascularization and fistula formation are a specific sign for the presence of left atrial appendage thrombus in patients with rheumatic mitral stenosis. 3 However, the direct proof that the angiographic neovascularity and fistula are truly within a thrombus is still lacking. In this study TEE was performed simultaneously with coronary angiography. The angiographic stain of opacified blood was found to represent neovascularity within the left atrial thrombus, and the jets of blood squirting into the left atrium seen on
Volume 5 Number 5 September-October 1992
Contrast TEE of coronary artery fistula
4 73
Figure 2 Top, Control TEE (in transverse plane) shows a left atrial appendage thrombus. Bottom, Mter selective injection of contrast medium in the left coronary artery, the echocardiogram shows dense contrast echo (arrows) emerging from a single drainage site (arrcnv head) on the surface of the thrombus into the left atrium.
coronary angiography were shown to be a fistula with its drainage site on the surface of the thrombus. In this study we reaffirmed the usefulness of contrast echocardiography as an imaging modality in the visualization of the exact drainage sites of coronary artery fistula as previously shown by Reeder et al. 1 and Cooper et al. 2 in cases of congenital coronary artery fistulae. In our patients with severe mitral stenosis and left atrial appendage thrombus, the drainage site of an acquired coronary artery fistula arising from the left circumflex artery could only be elucidated by simultaneous contrast TEE and coronary
angiography. The reason for this is that transthoracic echocardiography is not suited for imaging the left atrial appendage area. With the advent of TEE, the left atrial appendage could be visualized relatively easily. The close proximity of the esophagus to the left atrium permits the use of a high-frequency (5 MHz) transducer and evaluation of various crosssectional planes of the left atrium through proper adjustment of the position of the transducer. Therefore, we have demonstrated for the first time the usefulness of contrast TEE in imaging the exact drainage site of a coronary artery fistula from left atrial appendage thrombus.
474
Lo et al.
REFERENCES l. Reeder GS, Tajik AJ, Smith HC. Visualization of coronary artery fistula by two-dimensional echocardiography. Mayo Clin Proc 1980;55:185-9. 2. Cooper MJ, Bernstein D, Silverman NH. Recognition of left coronary artery fistula to the left and right ventricle by contrast echocardiography. J Am Coli Cardiol 1985;6:923-6. 3. Fu M, Hung JS, Lee CB, et al. Coronary neovascularization
Journal of the American Society of Echocardiography
as a specific sign for atrial left appendage thrombus in mitral stenosis. Am J Cardioll991;67:ll58-60. 4. Aschenberg W, Schluter M, Kremer P, Schroder E, Siglow V, Bleifeld W. Transesophageal two-dimensional echocardiography for the detection of left atrial appendage thrombus. J Am Coli Cardiol 1986;7:163-6. 5. Standen JR. "Tumor vascularity'' in left atrial thrombus demonstrated by selective coronary arteriography. Diagnostic Radiology 1975;116:549-50.
