European Journal of Echocardiography Advance Access originally published online on August 4, 2008
European Journal of Echocardiography 2009 10(1):175-177; doi:10.1093/ejechocard/jen215
Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2008. For permissions please email: journals.permissions@oxfordjournals.org.
Detection of myocardial ischaemia caused by coronary artery-left ventricular fistulae using myocardial contrast echocardiography
Omar Rana1,
Rosie Swallow2,
Roxy Senior3 and
Kim Greaves1,*
1 Department of Cardiology, Poole Hospital NHS Foundation Trust, Longfleet Road, Poole, Dorset BH15 2JB, UK
2 Department of Cardiology, Royal Bournemouth Hospital, Castle Lane East, Bournemouth BH7 7DW, UK
3 Department of Cardiology, Northwick Park Hospital, Watford Road, Harrow, Middlesex HA1 3UJ, UK
Received 5 June 2008; accepted after revision 17 July 2008; online publish-ahead-of-print 4 August 2008.
* Corresponding author. +44 120 244 2909; fax: +44 120 244 2754. E-mail address: kim.greaves{at}poole.nhs.uk
 |
Abstract
|
|---|
A coronary artery-left ventricular fistula (CAF) is an extremely
rare anatomical abnormality in which blood drains directly from
a coronary artery into the left ventricle. CAF may cause myocardial
ischaemia and angina. Myocardial contrast echocardiography (MCE)
is a non-invasive technique which assesses myocardial perfusion.
We describe a patient with CAF in whom transmural myocardial
ischaemia was demonstrated using MCE.
Keywords: Myocardial ischaemia; Coronary artery-left ventricular fistula; Myocardial contrast echocardiography
|
Case report
|
|---|
A 73-year-old man was admitted with history of cardiac sounding
chest pain at rest. Apart from mild chronic obstructive pulmonary
disease (COPD) which was well controlled with inhalers, there
was no other significant past medical history. Systemic examination
was unremarkable. Serial ECGs and 12-h post-admission troponin
were normal. A 12-lead exercise treadmill ECG was stopped at
3 min and 28 s due to chest tightness and breathlessness. There
were no significant ECG changes. Transthoracic echocardiography
was normal. Selective coronary angiography demonstrated a normal
left main stem, normal right coronary artery, and a non-flow
limiting stenosis in the proximal circumflex artery. In the
left anterior descending artery, multiple coronary artery-left
ventricular fistulae (CAF) were observed to arise from a large
proximal diagonal vessel and drain directly into the left ventricle
(see arrow in
Figure 1 and
Supplementary data, Video 1).
We performed both real-time imaging to assess wall motion, and
low power myocardial contrast echocardiography (MCE) with triggered
imaging following microbubble destruction to assess myocardial
perfusion, with dobutamine as the stressor agent. The patient
was on no antianginal medications and in the light of patient's
history of chronic obstructive pulmonary disease , dipyridamole
was not used. End-systolic images were obtained with a low mechanical
index (MI) of 0.1 with high-intensity pulses to facilitate microbubble
destruction followed by acquisition of 10 end-systolic frames.
Resting images showed both normal wall motion and myocardial
perfusion (
Figure 2 and
Supplementary data, Video 2). As
peak stress wall motion remained normal, however, following
microbubble destruction, there was a transmural perfusion defect
in the apical anterior and apical anterolateral walls, with
normal perfusion in the remaining walls (
Figure 3 and
Supplementary data, Video 3).
Owing to the size and multiplicity of the fistulae, medical
management in the form of anti-anginal agents was opted. The
patient has not had a recurrence of his angina 1 year after
his initial presentation.
|
Discussion
|
|---|
A coronary artery fistula is a communication between one of
the coronary arteries and a cardiac chamber or vein. Coronary
artery fistulae have an incidence of 0.2% in patients undergoing
diagnostic cardiac catheterization.
1 The right and left coronary
arteries are involved in 55 and 35% of cases, respectively,
with involvement of both vessels in 5% of cases.
2 Coronary artery
fistulae may manifest as a single large communication in an
individual or as multiple tiny communications.
2 They represent
a shunt between the coronary system and the cardiac chamber
into which they drain. The most common drainage sites are the
right ventricle (40%) and right atrium (23%).
1 Coronary artery-left
ventricular fistulae are exceedingly rare with the incidence
being reported as 1.2% of all coronary artery fistulae.
3 In
the presence of a small-shunt myocardial blood flow is not compromised.
However, large shunts may present with pulmonary oedema, pulmonary
hypertension, infective endocarditis, rupture, or thrombosis
of the fistula, an associated arterial aneurysm or myocardial
ischemia distal to the fistula (‘myocardial steal phenomenon’.)
Transcatheter and surgical closure techniques have been described
for the treatment of this anomaly.
3 However, interventional
procedures are reserved for large, clinically significant coronary
artery fistulae. The presence of multiple small fistulae and
the control of symptoms with medical management in our patient
precluded the use of these options.
Transthoracic echocardiography has been shown to be able to visualize large coronary artery fistulae directly.4 The vessels from which these fistulae arose were dilated and continuously turbulent on colour Doppler echocardiography. However, the majority of patients were children with large and proximally located congenital coronary artery fistulae. The authors concluded that the findings could not be extrapolated to an adult population.
There are several possible reasons why the CAF were not visualized directly on transthoracic echocardiography. First, the multiple CAF in this case were distally positioned in the coronary circulation and were of smaller calibre. These factors made them much more difficult to detect, particularly during ventricular systole. However, it is possible that they may have been visualized with contrast if a higher MI had been used. This could have allowed visualization of both myocardial tissue and contrast agent simultaneously. The reason for a lack of wall motion defect is due to the lower sensitivity of wall motion in comparison with perfusion in the detection of ischaemia.5 Contrast-enhanced transoesophageal echocardiography has also been used to diagnose CAF in adults and is thought to be more sensitive.6,7
Cardiac magnetic resonance imaging has been shown recently to demonstrate global subendocardial ischaemia due to multiple coronary–ventricular fistulae arising from all three major coronary arteries.8 Our group used low-power MCE, which demonstrated a transmural myocardial perfusion defect in the territory of the LAD wall despite normal wall motion. To our knowledge, this is the first report in which MCE has demonstrated myocardial ischaemia in the context of CAF.
|
Supplementary data
|
|---|
Supplementary data are available at European Journal of Echocardiography online.
|
References
|
|---|
- Bulut S, Al Hashimi HMM, Gehlmann HR. Multiple Coronary Artery Fistulae or Thebesian Veins? Heart (2007) 93:1267.[Free Full Text]
- Braunwald E. Braunwald's Heart Disease (2005) 7th ed. New York: Elsevier.
- Armsby LR, Keane JF, Sherwood MC, Forbess JM, Perry SB, Lock JE. Management of coronary artey fistulae: patient selection and results of transcatheter closure. J Am Coll Cardiol (2002) 39:1026–32.[Abstract/Free Full Text]
- Barbosa MM, Katina T, Oliveira HG, Neuenschwander FE, Oliveira HG. Doppler echocardiographic features of coronary artery fistula: report of 8 cases. J Am Soc Echocardiogr (1999) 12:149–54.[CrossRef][Web of Science][Medline]
- Elhendy A, O'Leary EL, Xie F, McGrain AC, Anderson JR, Porter TR. Comparative accuracy of real-time myocardial contrast perfusion imaging and wall motion analysis during dobutamine stress echocardiography for the diagnosis of coronary artery disease. J Am Coll Cardiol (2004) 44:2185–2191.[Abstract/Free Full Text]
- Goswami N, Zabalgoitia M. Localization of a coronary artery fistula using contrast transesophageal echocardiography. J Am Soc Echocardiogr (2002) 15:839–40.[CrossRef][Web of Science][Medline]
- López-Candales A, Kumar V. Coronary artery to left ventricle fistula. Cardiovasc Ultrasound (2005) 3:35–40.[CrossRef][Medline]
- Strange JW, Bucciarelli-Ducci C, Mathur A, Pennell DJ. Multiple coronary fistulae. A cause of subendocardial ischemia. Circ (2008) 117:853–6.[Free Full Text]
CiteULike 
Connotea 
Del.icio.us What's this?
Top
Abstract
Case report
