Current characteristics of congenital coronary artery fistulas in adults:A decade of global experience

AIM:To describe the characteristics of coronary artery fistulas(CAFs) in adults,including donor vessels and whether termination was cameral or vascular. METHODS:A PubMed search was performed for articles between 2000 and 2010 to describe the current characteristics of congenital CAFs in adults.A group of 304 adults was collected.Clinical data,presentations,diagnostic modalities,angiographic fistula findings and treatment strategies were gathered and analyzed.With regard to CAF origin,the subjects were tabulated into unilateral,bilateral or multilateral fistulas and compared.The group was stratified into two major subsets according to the mode of termination;coronary-cameral fistulas(CCFs) and coronary-vascular fistulas(CVFs) . A comparison was made between the two subsets. Fistula-related major complications[aneurysm formation,infective endocarditis(IE) ,myocardial infarction(MI) ,rupture,pericardial effusion(PE) and tamponade] were described.Coronary artery-ventricular multiple micro-fistulas and acquired CAFs were excluded as well as anomalous origin of the coronary arteries from the pulmonary artery(PA) . RESULTS:A total of 304 adult subjects(47%male) with congenital CAFs were included.The mean age was51.4 years(range,18-86 years) ,with 20%older than 65 years of age.Dyspnea(31%) ,chest pain(23%) and angina pectoris(21%) were the prevalent clinical presentations.Continuous cardiac murmur was heard in 82%of the subjects.Of the applied diagnostic modalities,chest X-ray showed an abnormal shadow in 4%of the subjects.The cornerstone in establishing the diagnosis was echocardiography(68%) ,and conventional contrast coronary angiography(97%) .However,multislice detector computed tomography was performed in 16%.The unilateral fistula originated from the left in 69%and from the right coronary artery in 31%of the subjects.Most patients(80%) had unilateral fistulas,18%presented with bilateral fistulas and 2%with multilateral fistulas.Termination into the PA was reported in unilateral(44%) ,bilateral(73%) and multilateral(75%) fistulas.Fistulas with multiple origins(bilateral and multilateral) terminated more frequently into the PA(29%) than into other sites(10.6%)(P=0.000) . Aneurysmal formation was found in 14%of all subjects.Spontaneous rupture,PE and tamponade were reported in 2%of all subjects.In CCFs,the mean age was 46.2 years whereas in CVFs mean age was 55.6 years(P=0.003) .IE(4%) was exclusively associated with CCFs,while MI(2%) was only found in subjects with CVFs.Surgical ligation was frequently chosen for unilateral(57%) ,bilateral(51%) and multilateral fistulas(66%) ,but percutaneous therapeutic embolization(PTE) was increasingly reported(23%,17%and 17%,respectively) . CONCLUSION:Congenital CAFs are currently detected in elderly patients.Bilateral fistulas are more frequently reported and PTE is more frequently applied as a therapeutic strategy in adults.

Incidental congenital coronary artery vascular fistulas in adults:Evaluation with adenosine-13N-ammonia PET-CT

AIM To assess the functionality of congenital coronary artery fistulas(CAFs) using adenosine stress ^(13)N-ammonia positron emission tomography computed tomography(PET-CT).METHODS Congenital CAFs were incidentally detected during coronary angiography(CAG) procedures in 11 adult patients(six males and five females) with a mean age of 64.3 years(range 41-81). Patients were collected from three institutes in the Netherlands. The characteristics of the fistulas(origin, pathway and termination), multiplicity of the origins and pathways of the fistulous vessels were assessed by CAG. Five patients underwent adenosine pharmacologic stress ^(13)N-ammonia PET-CT to assess myocardial perfusion and the functional behavior of the fistula. RESULTS Eleven patients with 12 CAFs, 10 unilateral and one bilateral, originating from the left anterior descending coronary artery(n = 8), right coronary artery(n = 2) and circumflex(n = 2). All fistulas were of the vascular type, terminating into either the pulmonary artery(n = 11) or coronary sinus(n = 1). The CAG delineated the characteristics of the fistula(origin, pathway and termination). Multiplicity of the origins and pathways of the fistulous vessels were common in most fistulas(8/12, 67% and 9/12, 75%, respectively). Multiplicity was common among the different fistula components(23/36, 64%). Adenosine pharmacologic stress ^(13)N-ammonia PET-CT revealed normal myocardial perfusion and ejection fraction in all but one patient, who showed a reduced ejection fraction.CONCLUSION PET-CT may be helpful for assessing the functional status of congenital CAFs in selected patients regarding clinical decision-making. Studies with a larger patient series are warranted.

Coronary Artery Fistula and Its Imaging Modalities—A Review Article

Coronary artery fistula (CAF) is known be a rare defect of coronary artery. When there is an abnormal pre-capillary communication between single or multiple branches of the coronary artery and any of the cardiac chambers or great vessels, it is designated as CAF. It can be found in both congenital and acquired form. Congenital origin of fistula occupies higher percentage compared to the acquired one. A wide variety of imaging modalities have been lunched to provide the best possible way to access and treat the defect. With regard to the assessment of the coronary artery fistula, trans-thoracic Doppler echocardiography and multi-slice CT (MSCT) angiography have commendable role, however, MSCTA comes in the leading position.

Novel treatment of coronary artery fistulae concealing severe coronary artery lesion： using thrombus aspiration catheter as a delivery guide

In this case report, we present the occlusion of multiple coronary artery fistulaes originating from proximal left anterior descending （LAD） and fight sinus valsavla and empting to the pulmonary artery at the same place. We occluded LAD fistulae by using thrombus aspira- tion catheter as a delivery guide. To the best of our knowlege, this is the first case of occlusion of coronary fistulaes with the help of throm- bus aspiration catheter. Our experience may suggest that thrombus aspiration catheters can be used in treating coronary artery fistulaes with difficult anotomv.

Application of interventional diagnostic and therapeutic technique for coronary artery fine branch fistula

Objective:To explore the value of angiographic diagnosis and interventional therapy of the coronary artery fine branch fistula.Methods:All of the 18 patients with coronary artery fine branch fistula underwent selective coronary arteriography,7 underwent interventional therapy, while 8 underwent prosthesis for coronary artery fistula (CAF) under extracorpored circulation. Results:Among 18 cases of coronary artery fine branch fistula, 7 happened in right coronary artery (38.9%), 11 in left coronary artery (61.1%). Among the 11 cases in left coronary artery,5 happened in descending anterior branch, 5 occurred in left circumflex branch, 1 arised from both left anterior branch and left circumflex branch. Among the 18 cases, there are 10 cases of coronary-to-pulmonary artery fistula (55.6%), 5 cases of fistula draining into right atrium (27.8%), 2 cases of fistula draining into left atrium (11.1%) and 1 draining into right ventricle (5.6%). Interventional treatment was successful in 7 patients. During the 12 months’ follow-up, there was no cardiovascular events. Conclusion:Selective coronary angiography is the first choice for diagnosing the coronary artery fine branch fistula. In respect of therapy, besides of surgical treatment, intervention is still a rather good measure presently.

Association between coronary artery stenosis and myocardial injury in patients with acute pulmonary embolism:A case-control study

Background:The potential impact of pre-existing coronary artery stenosis(CAS)on acute pulmonary embolism(PE)episodes remains underexplored.This study aimed to investigate the association between pre-existing CAS and the elevation of high-sensitivity cardiac troponin I(hs-cTnI)levels in patients with PE.Methods:In this multicenter,prospective case-control study,88 cases and 163 controls matched for age,sex,and study center were enrolled.Cases were patients with PE with elevated hs-cTnI.Controls were patients with PE with normal hs-cTnI.Coronary artery assessment utilized coronary computed tomographic angiography or invasive coronary angiography.CAS was defined as≥50%stenosis of the lumen diameter in any coronary vessel>2.0 mm in diameter.Conditional logistic regression was used to evaluate the association between CAS and hs-cTnI elevation.Results:The percentage of CAS was higher in the case group compared to the control group(44.3%[39/88]vs.30.1%[49/163];P=0.024).In multivariable conditional logistic regression model 1,CAS(adjusted odds ratio[OR],2.680;95%confidence interval[CI],1.243-5.779),heart rate>75 beats/min(OR,2.306;95%CI,1.056-5.036)and N-terminal pro-B type natriuretic peptide(NT-proBNP)>420 pg/mL(OR,12.169;95%CI,4.792-30.900)were independently associated with elevated hs-cTnI.In model 2,right CAS(OR,3.615;95%CI,1.467-8.909)and NT-proBNP>420 pg/mL(OR,13.890;95%CI,5.288-36.484)were independently associated with elevated hs-cTnI.Conclusions:CAS was independently associated with myocardial injury in patients with PE.Vigilance towards CAS is warranted in patients with PE with elevated cardiac troponin levels.

Coronary-cameral fistulas in adults(first of two parts)

This is a case series and review of the literature adding11 new cases.Coronary-cameral fistulas(CCFs)are infrequent anomalies which are in general co-incidentally found during diagnostic coronary angiography(CAG).To delineate the characteristics of congenital and acquired CCFs in adults,we performed a PubMed search for papers dealing with congenital or acquired CCFs in adults.Publications on coronary-vascular fistulas or paediatric subjects were not included.From the world literature,a total of 243 adult patients were identified who had congenital(65%)or acquired(35%)CCFs.In this review,which is part one of a two-part series on CCFs,we describe and discuss the congenital fistulas,give an overview on the published literature and report details of our own series of 11 patients with MMFs and solitary macro CCFs.Of the congenital group,56%were small or large solitary macro CCFs(cut-off 1.5mm)and 9%were coronary artery-ventricular multiple micro-fistulas(MMFs).Apical hypertrophic cardiomyopathy was reported in some of the reviewed subjects with MMFs(3/24=13%)but not was seen in our own series.Conservative medical management was generally the treatment of choice in congenital MMFs;prophylactic implantable cardioverter defibrillators(ICD)were implanted in 2/24(8%)of subjects,especially when extensive micro-fistulisations were involved.None of the patients of our own series required an ICD,as the MMFs were of limited size.Congenital or acquired CCFs in adults are infrequent anomalies having a wide spectrum of clinical presentation may varies from asymptomatic to severely devastating states requiring different treatment modalities.

Comparative Nursing Study of Patients Undergoing Coronary Intervention Therapy in Different Ways

Purpose: To compare the surgical indicators, perioperative complications and postoperative psychological status of patients with coronary interventional therapy (CIT) by radical artery and femoral artery puncture approaches. Methods: 120 patients with CIT were divided into femoral artery group (FAG) and radial artery group (RAG) according to the operation ways. The interventional operation was performed by the same surgeon team and methods. Data of surgical indicators and perioperative complications were recorded and collected. The psychological questionare survey was made within 48 hours the after surgery by the hospital anxiety and depression scale (HAD), and the results were scored by the psychiatrist. Results: The age, sex, ethnicity, education level, disease type, and combined diseases of the two groups had homogeneity without statistical difference. There was no obvious difference in X-ray exposure time, contrast agent usage and operation time in two ways (P > 0.05). The success rate of one-time catheterization was higher in FAG than in RAG (P Conclusion: CIT via radial artery can reduce the incidence of postoperative complications, postoperative physical discomfort and psychological problems such as anxiety and depression of patients.

右副冠状动脉-肺动脉瘘1例

患者女,60岁,间断劳累后胸闷伴心悸、出汗、恶心1周,休息20~30 min后可缓解;7年前无明显诱因晕厥1次,未接受系统诊治;高血压病史2年,规律用药。查体:血压150/105 mm Hg,心肺查体未见明显异常。实验室检查及心电图未见明显异常。超声心动图:左心室舒张末期容积118 ml,左心室舒张功能减低。

冠脉CTA对冠状动脉肺动脉瘘合并动脉瘤的诊断

目的评价MSCT对冠状动脉-肺动脉瘘(CPF)合并动脉瘤的诊断价值。方法回顾性分析冠状动脉CTA检查中发现的24例冠状动脉-肺动脉瘘患者的影像资料,总结其影像特征。结果24例冠状动脉-肺动脉瘘患者中,双侧冠状动脉瘘入肺动脉共14例,右侧冠状动脉瘘入肺动脉共6例,左侧冠状动脉瘘入肺动脉共4例。合并动脉瘤15例,瘤体单发6例,多发9例。结论冠脉CTA能准确判断CPF的有无,可清晰全面显示动脉瘤的位置、形态及大小,对CPF合并动脉瘤的早期诊断及制订治疗方案有重要价值。

血管内超声与冠状动脉造影指导的经皮冠状动脉介入治疗左主干病变的研究机制

目的探讨血管内超声与冠状动脉造影指导的经皮冠状动脉介入治疗左主干病变的效果。方法回顾性分析220例左主干病变患者的临床资料,全部患者均行左主干支架置入术治疗,超声组使用血管内超声引导(n=80),造影组应用冠状动脉造影引导(n=140),对两组治疗预后进行比较。结果相较于造影组,超声组治疗后取得了更高的球囊对吻扩张率、后扩张率、双支架术应用率以及操作成功率(P<0.05);相较于造影组,超声组治疗后取得了更低的心肌梗死、再次血运重建率(P<0.05);两组靶血管血运重建率与靶病变血运重建率差异无统计学意义(P>0.05)。结论在对左主干病变进行治疗时,相较于冠状动脉造影,血管内超声指导下经皮冠状动脉介入治疗可取得更好的效果,具备更高的安全性。

Reproducibility of thrombus volume quantification in multicenter computed tomography pulmonary angiography studies

AIM To evaluate reproducibility of pulmonary embolism(PE) clot volume quantification using computed tomography pulmonary angiogram(CTPA) in a multicenter setting.METHODS This study was performed using anonymized data in conformance with HIPAA and IRB Regulations(March 2015-November 2016). Anonymized CTPA data was acquired from 23 scanners from 18 imaging centers using each site's standard PE protocol. Two independent analysts measured PE volumes using a semi-automated region-growing algorithm on an FDA-approved image analysis platform. Total thrombus volume(TTV) was calculated per patient as the primary endpoint. Secondary endpoints were individual thrombus volume(ITV), Qanadli score and modified Qanadli score per patient. Inter-and intra-observer reproducibility were assessed using intra-class correlation coefficient(ICC) and BlandAltman analysis. RESULTS Analyst 1 found 72 emboli in the 23 patients with a mean number of emboli of 3.13 per patient with a range of 0-11 emboli per patient. The clot volumes ranged from 0.0041-47.34 cm3(mean +/-SD, 5.93 +/-10.15 cm3). On the second read, analyst 1 found the same number and distribution of emboli with a range of volumes for read 2 from 0.0041 – 45.52 cm3(mean +/-SD, 5.42 +/-9.53 cm3). Analyst 2 found 73 emboli in the 23 patients with a mean number of emboli of 3.17 per patient with a range of 0-11 emboli per patient. The clot volumes ranged from 0.00459-46.29 cm3(mean +/-SD, 5.91 +/-10.06 cm3). Inter-and intraobserver variability measurements indicated excellent reproducibility of the semi-automated method for quantifying PE volume burden. ICC for all endpoints was greater than 0.95 for inter-and intra-observer analysis. Bland-Altman analysis indicated no significant biases.CONCLUSION Semi-automated region growing algorithm for quantifying PE is reproducible using data from multiple scanners and is a suitable method for image analysis in multicenter clinical trials.

Evaluation of intracoronary function after reduction of ventricular rate by esmolol in severe stenotic myocardial bridge: A case report

BACKGROUND Severe stenotic myocardial bridges(MBs)have been reported to lead to intracoronary ischaemia,but the physiological evaluation of MBs using intracoronary function evaluation indicators after intraoperative drug treatment has not been fully established.CASE SUMMARY We performed through snuff fossa for coronary angiography in a patient with chest tightness after repeated exercise,and the results showed that the middle part of the anterior descending branch was a MB with 100%systolic compression.The intracoronary function evaluation(defined as the ratio of distal coronary pressure to aortic pressure with zero microcirculation resistance)was instantaneous wave-free ratio(IFR)without drug and fractional flow reserve(FFR)with adenosine.The IFR was 0.73,and the FFR was 0.66.Then esmolol 0.02μg/kg/min was intravenously injected.The IFR and FFR were measured again when the heart rate dropped to 60 beats/min.The IFR was 0.83,and the FFR 0.65.CONCLUSION This case report is a case of isolated MB with severe stenosis.After intraoperative drug treatment decreased the ventricular rate,an increase in the coronary function evaluation index was immediately observed to confirm the effective improvement of coronary blood flow.

冠状动脉瘘介入治疗的现状

冠状动脉瘘是一种冠状循环系统中罕见的异常,其特征是冠状动脉与心腔或大血管之间的异常连接。虽然大多数患者在临床上是无症状的,但是有一部分患者可以表现出充血性心力衰竭、心肌梗死、肺动脉高压和其他心肺功能异常的体征和症状。冠状动脉造影和冠状动脉CT血管造影被认为是诊断冠状动脉瘘的可靠方法。导管闭合术通常被认为是主要的治疗方法。本文综述冠状动脉瘘介入治疗现状并汇总研究进展。

皮下注射硝酸甘油应用于经鼻烟壶区桡动脉置管的随机对照研究

目的探究皮下注射硝酸甘油在经鼻烟壶区桡动脉穿刺置管操作中的临床价值。方法选取2021年7月至2023年2月广东省中医院珠海医院拟行经皮冠脉造影术的患者205例,采用数字奇偶法随机将其分为对照组(102例)和研究组(103例)。对照组穿刺处皮下注射利多卡因与盐水混合液,研究组穿刺处皮下注射利多卡因与硝酸甘油混合液,比较两组动脉管腔长、短径,首针穿刺成功比例、穿刺针数、置管成功时间、置管成功率、血管痉挛发生率、鞘管型号比例、血肿发生率、术后24 h桡动脉闭塞发生率。结果两组给药后平均动脉压差、心率差比较,差异无统计学意义(P>0.05);研究组血管痉挛发生率低于对照组,置管成功率高于对照组,差异有统计学意义(P<0.05);局麻后,研究组鼻烟壶区桡动脉管腔长、短径长于局麻前血管痉挛发生率低于对照组,差异有统计学意义(P<0.05),对照组局麻前后比较,差异无统计学意义(P>0.05);局麻后,研究组鼻烟壶区桡动脉管腔长、短径长于对照组,差异有统计学意义(P<0.05);研究组鞘管型号比例、首针穿刺成功比例、穿刺针数、置管成功时间、术中肝素用量及压迫止血时间比较,差异无统计学意义(P>0.05);两组术后血管痉挛发生率、术口血肿、前臂血肿、近桡闭塞、远桡闭塞、夹层、超声管腔直径比较,差异无统计学意义(P>0.05)。结论经鼻烟壶区桡动脉穿刺置管术前皮下注射硝酸甘油能扩张动脉,减少置管前桡动脉痉挛发生,提高置管成功率,具有良好的安全性,值得临床推广使用。

成人冠状动脉瘘CT冠状动脉血管成像的影像学特征及诊断

目的分析成人冠状动脉瘘(CAF)的CT冠状动脉血管成像(CTCA)表现特征,并探讨CTCA对成人CAF的诊断价值。方法回顾性选取行CTCA检查并确诊CAF成人患者31例。观察容积再现(VR)、曲面重建(CPR)及最大密度投影(MIP)等重建后图像信息,记录CAF的起源、瘘血管形态特征及瘘口位置,分析CAF的CTCA影像学特征及其诊断价值。结果31例经CTCA诊断的CAF患者,起源于左冠状动脉10例(32.2%)、右冠状动脉3例(9.7%)、左右冠状动脉双侧起源18例(58.1%)。冠状动脉-肺动脉瘘25例(80.6%)、冠状动脉-左心室瘘2例(6.5%)、冠状动脉-左心房瘘1例(3.2%)、冠状动脉-右心室1例(3.2%)、冠状动脉-冠状静脉窦瘘2例(6.5%)。结论CTCA可清晰显示CAF的起源、瘘血管形态、瘘口位置及特征性表现,是无创性诊断成人CAF的首选方法。

超声心动图联合CT造影诊断先天性冠状动脉瘘的诊断价值

目的 通过诊断效能剖析经胸超声心动图(TTE)联合冠状动脉CT血管造影(CTA)诊断先天性冠状动脉瘘(CAF)的准确性,阐述其影像学特征并讨论两种检查方式的诊断价值。方法 经PACS系统选取陕西省人民医院2016~2021年间先行TTE怀疑冠状动脉瘘的患者22例,再行CTA后,均经外科手术或冠状动脉造影后确诊冠状动脉瘘患者16例,其他患者6例。采用多因素logistic回归分析,绘制受试者工作特征(ROC)曲线分析来评估三种诊断方式的性能。结果 16例冠状动脉瘘患者中,Ⅰ型瘘入右心室1例;Ⅱ型瘘入右心房1例;Ⅲ型瘘入左心室3例;Ⅳ型瘘入左心房1例;Ⅴ型瘘入肺动脉10例。其中TTE确诊13例,漏诊3例;CTA确诊14例,漏诊2例;TTE联合CTA确诊15例,漏诊1例。漏诊均为左冠状动脉-肺动脉瘘。其中8例为多发瘘口,瘘口内径1.0~9.6 mm,6例形成冠状动脉瘤,较大者117×51 mm。经诊断效能分析,TTE联合CTA诊断CAF特异度(83.3%)高于TTE(50.0%)和CTA(66.7%),TTE联合CTA诊断CAF敏感度(93.7%)高于TTE(81.3%)和CTA(87.5%),TTE联合CTA诊断CAF阴性预测值(83.3%)高于TTE(50.0%)和CTA(66.7%),ROC曲线下面积TTE(AUC=0.906,95%CI:0.780~1.000,P<0.05),CTA(AUC=0.938,95%CI:0.834~1.000,P<0.05),TTE联合CTA(AUC=0.969,95%CI:0.895~1.000,P<0.05)。结论 TTE联合CTA诊断结果得出,先天性冠状动脉瘘Ⅴ型较为常见。经胸超声心动图联合CT血管造影提高诊断效能,值得临床推广应用。

Transcatheter coil embolization of multiple coronary artery-to-left ventricle fistulas： report of a rare case

Coronary artery fistula （CAF） is uncommon but remains the most frequent hemodynamically significant congenital coronary artery anomaly.The majority of fistula is single and drains into the right heart, only 3.5% into the left ventricle.^2 A large fistula requires closure to prevent complications such as myocardial ischemia resulting from coronary steal, congestive heart failure, endocarditis and potential aneurysmal dilatation and rupture.^3-5 Here we presented a rare case of CAF with multiple origins involving left anterior descending artery （LAD）, left circumflex branch （LCX） and right coronary artery （RCA）, and draining into the left ventricle, which was successfully closed by coil embolization.

冠状动脉CT血管成像对慢性完全闭塞病变介入治疗的应用价值分析

目的 探讨冠状动脉CT血管成像对慢性完全闭塞病变介入治疗的应用价值。方法 选取2019年3月-2021年3月收治的96例慢性完全闭塞病变介入治疗的患者为研究对象,将术前行冠状动脉CT血管成像检查的50例患者纳入甲组,将术前未行冠状动脉CT血管成像检查的46例患者纳入乙组,对比2组血管再通率、导丝未通过率、并发症发生率、手术用时、介入治疗成功率、左室收缩功能及甲组不同治疗结局的闭塞病变时长、CT值与病变长度。结果 甲组血管再通率及介入治疗成功率显著高于乙组(P<0.05);甲组导丝未通过率及并发症发生率显著低于乙组,手术用时短于乙组(P<0.05);手术前后2组患者的左室室壁运动指数及左室射血分数变化显著,甲组左室室壁运动指数较术前显著下降,且低于乙组(P<0.05),左室射血分数较术前上升,且高于乙组(P<0.05);相比较介入治疗失败者,甲组介入治疗成功者的闭塞病变时间更短、CT值更低且病变长度更短(P<0.05)。结论 针对慢性完全闭塞病变介入治疗患者,采用冠状动脉CT血管成像技术可提高血管再通率及治疗成功率,降低导丝未通过率及并发症发生率,缩短手术用时,改善患者心室功能。