European Journal of Echocardiography Advance Access originally published online on May 10, 2007
European Journal of Echocardiography 2008 9(3):410-411; doi:10.1016/j.euje.2007.03.028
Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2007. For permissions please email: journals.permissions@oxfordjournals.org
Acquired coronary fistula after left ventricular de-airing by apical needle aspiration
Philippe Unger1,2,*,
Mickael Moreels1,2,
Eric Stoupel1,2 and
Didier de Cannière1,2
1 Department of Cardiology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
2 Department of Cardiac Surgery, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
Received 24 January 2007; accepted after revision 16 March 2007; online publish-ahead-of-print 10 May 2007.
* Corresponding author: Department of Cardiology, Erasme University Hospital, 808, route de Lennik, B-1070 Brussels, Belgium. Tel: + 32 25553907; fax: + 32 25554609. E-mail address: philippe.unger{at}erasme.ulb.ac.be
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Abstract
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Acquired coronary fistula is uncommon, but has been reported
to occur after several surgical procedures, acute myocardial
infarction, endomyocardial biopsy, coronary angioplasty, and
thoracic trauma. We describe the occurrence of a left coronary
to left ventricular cavity fistula following resection of a
left atrial myxoma, with spontaneous closure in the following
weeks. The fistula was likely caused by a needle inserted into
the left ventricular apex, a procedure routinely used to ensure
left ventricular de-airing.
Keywords: Coronary fistula; Echocardiography; Myxoma
Left ventricular (LV) de-airing is performed at the end of cardiac
surgical procedures involving the left heart chambers and/or
aortic incision(s).
1 During such interventions, air can be trapped
in the left ventricle and/or the left atrium, and be ejected
into the arterial blood stream during subsequent cardiac systole.
Several venting maneuvers are used to avoid the risk of peripheral
air embolism. Among these, insertion of a needle allowing air
aspiration from the apex is routinely performed.
1 We describe
a patient who developed a coronary fistula following this maneuver.
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Case report
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A 53-year-old man had a small pedunculated left atrial myxoma
(2
x 2.5
x 2.5 cm) excised including wide resection of the pedicle
base. At the end of the procedure, LV de-airing was performed,
with insertion of a 16-gauge needle into the LV apex. Preoperative
coronary angiogram was normal, with a left anterior descending
(LAD) coronary artery wrapped around the apex. The operation
was uneventful. It is noteworthy that apical puncture is performed
under direct visual control at a distance from the apical LAD
coronary artery, where visible. Routine transthoracic echocardiogram
performed on the 5th postoperative day demonstrated an unexpected
and unusual LV apical diastolic flow (
Figure 1A and B).
Continuous wave Doppler showed predominantly diastolic flow
directed towards the left ventricle, with decreasing velocities
after the early diastolic maximal velocity (
Figure 1C).
In addition, a color-flow Doppler study showed continuity with
an antegrade diastolic flow in the apicoseptal region, consistent
with the location of the LAD coronary artery (
Figure 2).
These findings were consistent with a coronary to LV fistula,
2 presumably originating from a branch of the LAD coronary artery.
No segmental abnormality of LV contractility was seen. Because
the preoperative coronary angiography had been normal, the fistula
was considered to be secondary to the needle de-airing that
had been performed at the end of the surgery. In the absence
of symptoms, and in view of the small size of the fistula, no
attempt was made to close it. Apical flow was still observed
on postoperative day 15, but the subsequent control echocardiogram,
performed on the 27th postoperative day, did not show any residual
abnormal flow, suggesting spontaneous closure of the fistula.
It is noteworthy that no cardiac murmur was heard at any time
while the fistula was patent.
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Figure 1 Postoperative color-coded echocardiogram, showing left ventricular (LV) apical flow (arrow, panel A). This flow occurs during diastole, as demonstrated by color M-mode tracing (arrow, panel B), and is directed towards the LV cavity as shown by continuous wave Doppler (arrow, panel C). RV: right ventricle.
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Figure 2 Postoperative color-flow Doppler echocardiogram showing diastolic flow in the apical interventricular septum (IVS) directed towards the apex (thin arrows) and connected to the fistula (large arrow), consistent with a distal left anterior coronary artery. LV: left ventricle.
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Acquired coronary fistulas are uncommon. They have been described
after endomyocardial biopsy, coronary angioplasty, acute myocardial
infarction, thoracic trauma, and after several surgical procedures.
Surgical excision of a cardiac myxoma has been reported to induce
a coronary artery to atrial fistula, when neovascularization
was incorporated into the atrial suture line.
3,4 To our knowledge,
only two cases of coronary fistula following needle insertion
into the LV have been described, both in the French literature.
2,5 In both cases, the needle had been inserted through the right
ventricle and the interventricular septum, and in one of the
cases, the fistula was only diagnosed 6 years after surgery.
2 The present case suggests, however, that spontaneous early closure
may occur, supporting an initial conservative approach to treatment.
Despite the paucity of reports on needle-related iatrogenic
coronary fistulas, we hypothesize that the incidence of this
finding may be underestimated inasmuch as it is not common practice
to search for coronary fistulas after uncomplicated cardiac
surgery requiring LV de-airing, and as cardiac auscultation
may be insensitive in this setting. The real incidence of needle-related
iatrogenic coronary fistulas might be assessed during routine
postoperative echocardiography by including systematic color-flow
imaging of the LV apex. This complication could be prevented
by suturing the puncture orifice, and, in cases where the LAD
coronary artery is wrapped around the apex, by locating the
puncture site on a more lateral aspect of the LV.
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Acknowledgements
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Philippe Unger has received a grant from the
Fonds pour la Chirurgie Cardiaque.
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References
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- Kirklin JW, Barratt-Boyes BG. Hypothermia, circulatory arrest, and cardiopulmonary bypass. In: Cardiac surgery: morphology, diagnostic criteria, natural history, techniques, results, and indications (1993) New York: Churchill Livingstone. 99–109.
- Marek A, Rey JL, Tribouilloy C, Jarry G, Avinee P, Lesbre JP, et al. Postoperative iatrogenic left coronaroventricular fistula. Demonstration by color two-dimensional Doppler. Arch Mal Coeur Vaiss (1991) 84:419–23.[Web of Science][Medline]
- Burns AC, Osula S, Harley A, Rashid A. Left circumflex coronary to left atrial fistula in a patient with mitral regurgitation after excision of a left atrial myxoma. Ann Thorac Surg (2001) 72:1732–3.[Abstract/Free Full Text]
- Roth JE, Conner WC, Porisch ME, Shry E. Sinoatrial nodal artery to right atrium fistula after myxoma excision. Ann Thorac Surg (2006) 82:1106–7.[Abstract/Free Full Text]
- Jebara VA, Corbi P, Dreyfus G, Acar C, Chachques JC, Rovani X, et al. Postoperative iatrogenic coronary-ventricular fistula. Ann Radiol (Paris) (1991) 34:195–8.[Medline]
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