Multiple coronary-cameral fistulas to the left ventricle arising from both coronary arteries

RADIOLOGY IMAGE

Multiple coronary-cameral fistulas to the left ventricle arising from both coronary arteries

Ranjan Pathak, MD1, Smith Giri, MD2*, Inyong Hwang, MD2 and Shadwan Alsafwah, MD, FACC3

1Department of Medicine, Reading Health System, West Reading, PA, USA; 2Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA; 3Divison of Cardiovascular Diseases, University of Tennessee Health Science Center, Memphis, TN, USA

Abstract

Coronary-cameral fistula (CCF) is an anomalous connection between a coronary artery and a cardiac chamber or major vessel, seen in about 0.8% of the cases undergoing coronary angiography. Most patients are asymptomatic and diagnosis is made incidentally during coronary angiography. We present an image case of CCF which was found incidentally during pre-liver transplantation work up.

Keywords: coronary cameral fistula; coronary angiography; Management

Citation: Journal of Community Hospital Internal Medicine Perspectives 2016, 6: 31190 - http://dx.doi.org/10.3402/jchimp.v6.31190

Copyright: © 2016 Ranjan Pathak et al. This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License, permitting all non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Received: 1 February 2016; Revised: 20 April 2016; Accepted: 2 May 2016; Published: 6 July 2016

Competing interests and funding: The authors have not received any funding or benefits from industry or elsewhere to conduct this study.

*Correspondence to: Smith Giri, Department of Medicine, University of Tennessee Health Science Center, 956 Court Avenue, Room H314, Memphis, TN 38163, USA, Email: smithgiri963@gmail.com

 

A 57-year-old Caucasian female with a past medical history of diabetes mellitus, chronic obstructive pulmonary disease, and hepatitis C cirrhosis planned for orthotopic liver transplantation was admitted to the hospital. An elective cardiac catheterization was done as a part of pre-transplant workup. Cardiac catheterizations revealed normal coronaries, with multiple coronary-cameral fistulas (CCF) terminating in the left ventricle arising from both coronary arteries (Figs. 1 and 2). No interventions were done because of the asymptomatic nature of these fistulas.

Fig 1

Fig. 1.   Multiple coronary-cameral fistulas to the left ventricle arising from the left anterior descending and left circumflex arteries with opacification of the left ventricle.

Fig 2

Fig. 2.   Multiple coronary-cameral fistulas to the left ventricle arising from the right coronary artery with opacification of the left ventricle.

CCF is an anomalous connection between a coronary artery and a cardiac chamber or major vessel, seen in about 0.8% of the cases undergoing coronary angiography (1). Although the exact etiology is unknown, liver disease may be contributory in our patient, as it is known to cause a variety of systemic arteriovenous malformations. Most patients are asymptomatic, and diagnosis is made incidentally during coronary angiography. The usual sites of origin are right coronary artery (55%), left coronary artery (35%), and both (5%). Depending on the site of communication, they are classified as arterioluminal (direct communication with the cardiac chambers) or arteriosinusoidal (communication via sinusoidal network rather than direct communication) (2). Common sites of termination are right ventricle (40%), right atrium (26%), or pulmonary artery (17%) (1). Termination in the left ventricle is seen in about 1% of all cases of coronary artery fistula. Bi-arterial fistulization to the left ventricle is even rare with only a few cases reported in the literature (1).

Most cases of CCF are asymptomatic, detected accidentally, and conservatively managed with serial follow up (2, 3). The indication of treatment in CCF includes hemodynamically significant fistulas with worsening right to left shunts, left or right ventricular overload, myocardial ischemia, and congestive heart failure. Although there is no consensus on the optimal strategy, a variety of interventions including surgical repair, catheter closure, and medical management have been successfully utilized. Arterio-luminal subtype can be successfully closed by surgery, whereas arterisinusoidal type is less amenable to surgery and use of beta-blockers has been described (2).

References

  1. Hoffman JI. Congenital anomalies of the coronary vessels and the aortic root. In: Emmanoulides GC, Riemenschneider TA, Allen HD, Gutgesell HP eds. Heart disease in infants, children and adolescents. 5th ed. Baltimore, MD: Williams and Wilkins; 1995. p. 780.
  2. Nagpal P, Khandelwal A, Saboo SS, Garg G, Steigner ML. Symptomatic coronary cameral fistula. Heart Views 2015; 16(2): 65–7. PubMed Abstract | PubMed Central Full Text | Publisher Full Text
  3. Liberthson RR, Sagar KA, Berkoben JP, Weintraub RM, Levine FH. Congenital coronary arteriovenous fistula. Report of 13 patients, review of the literature and delineation of management. Circulation 1979; 59: 849–54. PubMed Abstract | Publisher Full Text
About The Authors

Ranjan Pathak
The Reading Hospital and Medical Center
United States

Department of Internal Medicine, Resident

Smith Giri
University of Tennessee Health Science Center
United States

Inyong Hwang
University of Tennessee Health Science Center
United States

Shadwan Alsafwah
University of Tennessee Health Science Center
United States

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