Korean Circ J.  2012 Dec;42(12):845-848. 10.4070/kcj.2012.42.12.845.

Hemodynamic Significance of Coronary Cameral Fistula Assessed by Fractional Flow Reserve

• Oh JH
• Lee HW
• Cha KS

• KMID: 1491101
• DOI: http://doi.org/10.4070/kcj.2012.42.12.845

Abstract

Coronary cameral fistula (CCF) is a rare anomaly, where a communication exists between an epicardial coronary artery and a cardiac chamber. Assessing the hemodynamic significance of the fistula is crucial to make a decision concerning the management process. We present two cases of CCF, draining into the left ventricle, in which the hemodynamic significance was assessed by a fractional flow reserve.

Keyword

Coronary vessels; Fistula; Myocardial ischemia; Myocardial bridging

MeSH Terms

Coronary Vessels
Fistula
Heart Ventricles
Hemodynamics
Myocardial Bridging
Myocardial Ischemia

Figure

• 

  Fig. 1 Selective left coronary angiography. A: anteroposterior view. The huge and tortuous left anterior descending and circumflex arteries merged at the end of their course forming a large coronary-left ventricular fistula (arrow) draining into the basal portion of the left ventricular cavity. B: anterior-posterior cranial view. There is no stenosis in the both coronary arteries.

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  Fig. 2 Fractional flow reserve (FFR). A: the FFR value of the left anterior descending coronary artery during hyperemia is 0.93. B: the FFR value of the left circumflex coronary artery during hyperemia is 0.97.

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  Fig. 3 Selective left coronary angiography. A: anteroposterior view demonstrates multiple coronary artery-left ventricular microfistulas (arrowheads). B: right anterior oblique and cranial view. The normal looking appearance of the left anterior descending coronary artery (LAD) in the diastolic phase (arrow) is shown. C: right anterior oblique and cranial view. Total compression of the bridging segment in the mid LAD at systole (arrow) is noted.

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  Fig. 4 Fractional flow reserve (FFR). A: the FFR value of the left anterior descending coronary artery during hyperemia is 0.92. B: the pull-back pressure recording with continuous intravenous adenosine infusion. Note that the intracoronary systolic pressure overshooting over the aortic pressure (arrowheads) and the abrupt early diastolic pressure gradient (arrow) in the segment distal to the bridge. Those characteristic findings disappeared after the sensor proceeded through the bridging segment with pull back maneuver.

Reference

1. Sapin P, Frantz E, Jain A, Nichols TC, Dehmer GJ. Coronary artery fistula: an abnormality affecting all age groups. Medicine (Baltimore). 1990. 69:101–113.

2. Rana O, Swallow R, Senior R, Greaves K. Detection of myocardial ischaemia caused by coronary artery-left ventricular fistulae using myocardial contrast echocardiography. Eur J Echocardiogr. 2009. 10:175–177.

3. Strange JW, Bucciarelli-Ducci C, Mathur A, Pennell DJ. Images in cardiovascular medicine. Multiple coronary fistulae: a cause of subendocardial ischemia. Circulation. 2008. 117:853–856.

4. Vavuranakis M, Bush CA, Boudoulas H. Coronary artery fistulas in adults: incidence, angiographic characteristics, natural history. Cathet Cardiovasc Diagn. 1995. 35:116–120.

5. Levin DC, Fellows KE, Abrams HL. Hemodynamically significant primary anomalies of the coronary arteries: angiographic aspects. Circulation. 1978. 58:25–34.

6. Liberthson RR, Sagar K, Berkoben JP, Weintraub RM, Levine FH. Congenital coronary arteriovenous fistula: report of 13 patients, review of the literature and delineation of management. Circulation. 1979. 59:849–854.

7. 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. 39:1026–1032.

8. Bamoshmoosh M, Marraccini P, Pratali L, Ciriello G, Ciardetti M, Mazzarisi A. "Reverse steal phenomenon" in a patient with coronary artery disease and coronary-left ventricular fistula. Int J Cardiol. 2007. 115:e33–e35.

9. Escaned J, Cortés J, Flores A, et al. Importance of diastolic fractional flow reserve and dobutamine challenge in physiologic assessment of myocardial bridging. J Am Coll Cardiol. 2003. 42:226–233.