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Published on: August 16, 2021
Nonhemorrhagic Pericardial Effusion With Tamponade and Cardiogenic Shock Due to Large Coronary Artery Fistula
Felix von Sanden1, Christian Skrabal2, Muhammad Arab2
1Department of Internal Medicine II, Cardiology, Angiology, Pneumology, Internal Intensive Care, Sports- and Rehabilitation Medicine, Ulm University Medical Center, Ulm, Germany.
Insights
Coronary artery fistulas (CAFs) can cause heart failure and shock. Prompt diagnosis and surgical closure of these rare congenital heart defects are crucial for symptom improvement in adults.
Area of Science:
- Cardiology
- Congenital Heart Disease
- Cardiac Surgery
Background:
- Coronary artery fistulas (CAFs) are rare congenital heart anomalies.
- Large CAFs can cause coronary steal syndrome, leading to symptoms like angina and heart failure.
- Rarely, CAFs can present with severe complications such as cardiogenic shock.
Observation:
- A 55-year-old woman presented with nonhemorrhagic pericardial tamponade and cardiogenic shock.
- Diagnostic imaging revealed a large CAF involving an aneurysmal right coronary artery draining into the coronary sinus.
- Initial management included pericardiocentesis for hemodynamic stabilization.
Findings:
- The patient's pericardial tamponade was attributed to acute right heart decompensation secondary to chronic right ventricular overload, rather than vessel rupture.
- Surgical repair involved cardiopulmonary bypass to close the fistulous connections between the right coronary artery and the coronary sinus.
Implications:
- This case highlights that pericardial tamponade in CAF can result from right heart failure, not solely hemopericardium.
- Early and comprehensive cardiac imaging is vital for diagnosing rare congenital conditions like CAFs in adults presenting with heart failure.
- Surgical closure of the fistula offers a significant potential for symptom relief and improved outcomes in affected individuals.
Background:
Coronary artery fistulas (CAFs) are a rare congenital heart disease. Large fistulas can lead to coronary steal phenomena presenting with angina, heart failure, and in rare cases, cardiogenic shock.
Case Summary:
A 55-year-old woman acutely presented at our heart center with nonhemorrhagic pericardial tamponade and cardiogenic shock. A large CAF of an aneurysmatic right coronary artery to the coronary sinus was diagnosed. Pericardiocentesis was used for initial hemodynamic stabilization. On cardiopulmonary bypass, perforations connecting right coronary artery and coronary sinus were closed via suture.
Discussion:
In cases of CAF, cardiogenic shock with pericardial tamponade is usually caused by rupture of an aneurysmatic vessel with successive hemopericardium. In this case, the pericardial tamponade was caused by acute right heart decompensation after long-term right ventricular overload.
Take-Home Messages:
In adult right heart failure, early comprehensive cardiac imaging is essential for diagnosis of rare underlying congenital diseases. Surgical shunt closure can drastically improve symptoms.
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