Transcutaneous closure of a huge multilocular coronary to right atrium fistula causing severe right side heart
Reda Abuelatta1, Hesham A Naeim1
1Madina Cardiac Center, Medina, Saudi Arabia.
Insights
Transcatheter closure effectively treated a large coronary artery fistula (CAF) causing heart failure. This minimally invasive approach offers a safe alternative to surgery for symptomatic patients with significant fistulas.
Area of Science:
- Cardiology
- Interventional Cardiology
- Congenital Heart Disease
Background:
- Coronary artery fistula (CAF) is an abnormal connection between a coronary artery and cardiac chambers or vessels.
- Clinical presentation varies based on fistula size and drainage site, often leading to heart failure.
Observation:
- A 40-year-old female presented with right-sided heart failure due to a substantial coronary to right atrium fistula.
- Diagnosis confirmed by echocardiography, CT, and 3D printing.
Findings:
- Transcatheter closure using an Amplatzer duct occluder successfully occluded the enormous, multiloculated CAF.
- The procedure preserved all coronary branches, with no fistula flow detected on follow-up echocardiography.
Implications:
- Transcatheter closure is a feasible and safe option for large, symptomatic CAFs, offering a less invasive alternative to surgery.
- Surgical intervention should be reserved for cases where percutaneous closure fails.
Abstract:
Coronary artery fistula (CAF) is a congenital connection between a coronary artery and cardiac chambers, or a vessel bypassing a capillary system. The clinical presentation of congenital CAF varies, depending on its size and the draining chamber. A 40-year-old female presented with right-sided heart failure and was diagnosed by transthoracic echocardiography and computed tomography with 3D printing to have substantial coronary to right atrium fistula. Left main artery was cannulated to the outlet of the fistula at the base of the superior vena cava to the right atrium. The wire snared and created the arterio-venous loop. A 7F delivery sheath through the arterio-venous loop landed in proximal left circumflex part of the fistula, Amplatzer duct occluder I size 12/10 selected with the distal (aortic) skirt positioned distal to the most distal visible coronary branch. We waited for 10 min monitoring the ST segments for any changes. Finally, the device was released with complete closure of the fistula sparing all coronary branches. Follow-up transthoracic echocardiography after six months showed no flow to fistula sacs; the patient's symptoms improved dramatically. In conclusion, transcatheter closure of an isolated enormous multiloculated CAF is feasible and relatively safe. Surgery should be reserved for CAF with failed percutaneous closure. <Learning objective: Coronary artery fistula (CAF) is a congenital connection between a coronary artery and cardiac chambers, or a vessel bypassing a capillary system. Closure of CAF is indicated for symptomatic patients or asymptomatic patients with huge fistulas. Transcatheter closure approaches are considered an alternative to surgical correction with proven efficacy and safety, with similar morbidity and mortality. Surgery should be reserved for CAF with failed percutaneous closure.>.
