Anatomical Classification and Posttreatment Remodeling Characteristics to Guide Management and Follow-Up of Neonates
Srinath T Gowda1, Larry Latson2, Kothandam Sivakumar3
1Department of Pediatrics, Lillie Frank Abercrombie Section of Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston (S.T.G., A.M.Q.).
Insights
Coronary artery fistulas (CAFs) in infants are rare. Treatment via transcatheter or surgical closure is successful, but distal CAFs pose a higher risk for suboptimal remodeling, necessitating follow-up.
Area of Science:
- Pediatric Cardiology
- Congenital Heart Disease
- Interventional Cardiology
Background:
- Coronary artery fistulas (CAFs) presenting in infancy are uncommon.
- Limited data exists on post-closure outcomes and follow-up for infantile CAFs.
Purpose of the Study:
- To evaluate outcomes and coronary remodeling after treatment of CAFs in neonates and infants.
- To assess the effectiveness of transcatheter and surgical closure methods.
- To identify risk factors for suboptimal remodeling.
Main Methods:
- Retrospective review of neonates and infants (<1 year) with CAFs from a registry.
- Analysis of CAF type, size, treatment, and follow-up angiography.
- Assessment of procedural success and coronary remodeling patterns.
Main Results:
- 48 patients included; 30 proximal and 18 distal CAFs; 39 large CAFs.
- Transcatheter and surgical closure showed high procedural success (92% and 94%).
- Distal CAFs had a higher rate of suboptimal remodeling (45%) compared to proximal CAFs (30%).
Conclusions:
- Transcatheter or surgical closure is effective for hemodynamically significant CAFs in infants.
- Distal CAFs are associated with an increased risk of suboptimal coronary remodeling.
- Post-closure anticoagulation and coronary anatomic evaluation are recommended.
Background:
Coronary artery fistulas (CAFs) presenting in infancy are rare, and data regarding postclosure sequelae and follow-up are limited.
Methods:
A retrospective review of all the neonates and infants (<1 year) was conducted from the CAF registry for CAF treatment. The CAF type (proximal or distal), size, treatment method, and follow-up angiography were reviewed to assess outcomes and coronary remodeling.
Results:
Forty-eight patients were included from 20 centers. Of these, 30 were proximal and 18 had distal CAF; 39 were large, 7 medium, and 2 had small CAF. The median age and weight was 0.16 years (0.01-1) and 4.2 kg (1.7-10.6). Heart failure was noted in 28 of 48 (58%) patients. Transcatheter closure was performed in 24, surgical closure in 18, and 6 were observed medically. Procedural success was 92% and 94 % for transcatheter closure and surgical closure, respectively. Follow-up data were obtained in 34 of 48 (70%) at a median of 2.9 (0.1-18) years. Angiography to assess remodeling was available in 20 of 48 (41%). I. Optimal remodeling (n=10, 7 proximal and 3 distal CAF). II. Suboptimal remodeling (n=7) included (A) symptomatic coronary thrombosis (n=2, distal CAF), (B) asymptomatic coronary thrombosis (n=3, 1 proximal and 2 distal CAF), and (C) partial thrombosis with residual cul-de-sac (n=1, proximal CAF) and vessel irregularity with stenosis (n=1, distal CAF). Finally, (III) persistent coronary artery dilation (n=4). Antiplatelets and anticoagulation were used in 31 and 7 patients post-closure, respectively. Overall, 7 of 10 (70%) with proximal CAF had optimal remodeling, but 5 of 11 (45%) with distal CAF had suboptimal remodeling. Only 1 of 7 patients with suboptimal remodeling were on anticoagulation.
Conclusions:
Neonates/infants with hemodynamically significant CAF can be treated by transcatheter or surgical closure with excellent procedural success. Patients with distal CAF are at higher risk for suboptimal remodeling. Postclosure anticoagulation and follow-up coronary anatomic evaluation are warranted.
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