Abstracts
Relatamos o caso de um paciente do sexo feminino, assintomática, com grande fístula bilateral da artéria coronária-artéria pulmonar. O monitoramento clínico foi a opção escolhida para tratamento. Discutimos os pormenores das opções terapêuticas, enfatizando a tendência excessiva de utilizar a abordagem cirúrgica e a grande escassez de acompanhamentos clínicos de longo prazo em pacientes assintomáticos.
Doença das coronárias; Fístula coronária; Anomalias coronárias
Relatamos el caso de un paciente del sexo femenino, asintomática, con gran fístula bilateral de la arteria coronaria-arteria pulmonar. El monitoreo clínico fue la opción elegida para el tratamiento. Discutimos los pormenores de las opciones terapéuticas, enfatizando la tendencia excesiva de utilizar el abordaje quirúrgico y la gran escasez de seguimientos clínicos de largo plazo en pacientes asintomáticos.
Enfermedad de las coronarias; fístula coronaria; anomalías coronarias
CASE REPORT
Large bilateral coronary artery fistula: the choice of clinical treatment
Luciana Oliveira Cascaes Dourado; Aécio Flávio Teixeira de Góis; Whady Hueb; Luiz Antônio Machado César
Instituto do Coração do Hospital das Clínicas da FMUSP, São Paulo, SP, Brazil
Mailing address
SUMMARY
We report the case of an asymptomatic female patient, with a large non-complicated bilateral coronary-pulmonary artery fistula. Clinical monitoring was the choice of treatment. We discuss the therapeutic options in depth, emphasizing the excessive tendency of the surgical approach and the great scarcity of reports on long-term clinical follow-up in asymptomatic patients.
Key words: Coronary Disease; Coronary Fistula; Coronary Abnormalities.
Case Report
The patient was a 49-year-old woman, ex-smoker, asymptomatic, with heart murmurs identified after a routine check-up. The patient was in good condition to undergo diagnostic examinations and did not report any significant past diseases. She reported leading an active life, regularly participating in sports. She also reported 2 successful pregnancies without any adverse events.
The patient underwent a physical examination and was found to be in good health, except for the presence of continued slight (innocent) heart murmurs with greater stress on the upper left sternal edge. The murmurs showed greater intensity during systole with a significant decrease in diastole. A breakdown of the second heart sound did not occur. The surface electrocardiogram and chest teleradiography were normal.
The transthoracic echocardiography (TTE) revealed normal global function, with the cardiac dimensions and systolic pressure of the pulmonary artery within normal standards. The TTE also revealed dilatation of the right coronary artery (RCA) and the left coronary artery (LCA). The LCA had a tortuous path with turbulent flow, leading into the pulmonary artery (PA). The coronary angiotomography showed that the anomalous artery branch with dilatation and significant tortuosity was located before the pulmonary artery, with its origin in the aorta, close to the emergence of the RCA, communicating with the anterior descending artery (ADA). This artery communicated with the PA in its mid third, emerging as a tortuous vessel (Figure 1). The percutaneous coronary angiography confirmed the previous findings. The myocardial perfusion imaging was normal.
Discussion
Coronary fistulae are characterized by anomalous communications between one or more branches of the coronary arteries, cardiac chambers' coronary sinus, superior vena cava, and the pulmonary artery.
The coronary anomalies are occasional and usually an incidental finding during the coronary angiography, with an estimated incidence of 0.6 to 1.5% in patients undergoing examination1-3. Most of the coronary fistulae are congenital, with causes that were probably acquired4. They represent a broad spectrum of sizes and anatomical variations, and each of them has different clinical implications. Most frequently, they originate from the RCA (55%)5.
It seems that half of the cases are symptomatic, with symptoms being unspecific2,4. In patients with symptomatic and bulky fistulae, the possible long-term complications include pulmonary hypertension and heart failure in cases of significant shunts; infectious endocarditis, thrombosis, or rupture of fistula; or myocardial ischemia secondary to the theft of myocardial flow1,4. However, studies of asymptomatic patients free of interventions are scarce.
A consensus regarding the ideal treatment of fistulae does not exist, especially when treating moderate and asymptomatic fistulae4. This lack of consensus is due to the scarcity of clinical follow-up of these patients. The few studies of conservative treatment with regular monitoring of the patients show good progress in the long-term5.
Most authors6-9 recommend surgery, fearing a possible risk of adverse events. Others4,5,10, however, describe successful conservative treatment in selected patients. They recommend regular clinical follow-up, with surgery if symptoms or an increase in the shunt occurs.
We suggest, therefore, clinical follow-up for asymptomatic patients and/or those without complications - ventricular dysfunction, ischemia, pulmonary hypertension - as in the case reported. In symptomatic patients or those with complications, however, percutaneous or surgical interventions are indicated, and these interventions are also better reported in the literature in these situations4.
Potential Conflict of Interest
No potential conflict of interest relevant to this article was reported.
Sources of Funding
There were no external funding sources for this study.
Study Association
This study is not associated with any post-graduation program.
References
- 1. Libby P, Bonow RO, Mann DL, Zipes DP. Braunwald's heart disease: a textbook of cardiovascular medicine.8th ed. Philadelphia: Elsevier Saunders; 2007.
- 2. Angelini P. Coronary fistulae: which ones deserve treatment, and what kind of treatment do they need? [Commentary]. Tex Heart Inst J. 2007; 34 (2): 202-3.
- 3. Cebi N, Schulze-Waltrup N, Frömke J, Scheffold T, Heuer H. Congenital coronary artery fistulas in adults: concomitant pathologies and treatment. Int J Cardiovasc Imaging. 2008; 24 (4): 349-55.
- 4. Luo L, Kebede S, Wu S, Stouffer GA. Coronary artery fistulae. Am J Med Sci. 2006; 332: 79-84.
- 5. Sherwood MC, Rockenmacher S, Colan SD, Geva T. Prognostic significance of clinical silent coronary artery fistulas. Am J Cardiol. 1999; 83: 407-11.
- 6. Mehta D, Redwood D, Ward DE. Multiple bilateral coronary arterial to pulmonary artery fistulae in an asymptomatic patient. Int J Cardiol. 1987; 16: 96-8.
- 7. Lowe JE, Oldham HN Jr, Sabiston DC Jr. Surgical management of congenital coronary artery fistulas. Ann Surg. 1981; 194: 373-80.
- 8. Macri R, Capulzini A, Fazzini L, Cornali M, Verunelli F, Reginato E. Congenital coronary artery fistula: report of five patients, diagnostic problems and principles of management. Thorac Cardiovasc Surg. 1982; 30: 167-71.
- 9. Armsby LR, Keane JF, Sherwood MC, Forbess JM, Perry SB, Lock JE. Management of coronary artery fistulae: patient selection and results of transcatheter closure. J Am Coll Cardiol. 2002; 39: 1026-32.
- 10. Cheung DLC, Au WK, Cheung HHC, Clement SW, Chin WTL. Coronary artery fistulas: long-term results of surgical correction. Ann Thorac Surg. 2001; 71: 190-5.
Correspondência:
Publication Dates
-
Publication in this collection
22 Oct 2009 -
Date of issue
Sept 2009
History
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Accepted
24 Mar 2009 -
Reviewed
27 Nov 2008 -
Received
05 Oct 2008
