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A rare case of aorto-to-pulmonary artery fistula associated with three coronary arteries-to-pulmonary artery fistulas
International Journal of Cardiology 176 (2014) e47–e48
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
A rare case of aorto-to-pulmonary artery fistula associated with three coronary arteries-to-pulmonary artery fistulas Chiara Valentina Lario a,⁎, Annalisa Balbo Mussetto a, Teresa Gallo a, Barbara Mabritto b, Margherita Castiglione Morelli c, Maria Rosa Conte b, Stefano Cirillo a a b c
Department of Radiology, A.O. Ordine Mauriziano, Torino, Italy Department of Cardiology, A.O. Ordine Mauriziano, Torino, Italy Department of Radiology, IRCCS A.O. U. San Martino — IST, Genova, Italy
a r t i c l e
i n f o
Article history: Received 19 May 2014 Accepted 5 July 2014 Available online 22 July 2014 Keywords: Cardiac CT Coronary arteries-to-main pulmonary fistulas Aorto-to-main pulmonary fistula
We report the case of a rare congenital aorto-pulmonary artery fistula combined with coronary artery fistulas. A 72 year-old man was admitted to our hospital due to chest pain and dyspnoea. ECG showed an ST elevation and serological parameters confirmed the diagnosis of acute coronary artery syndrome. Coronary angiography ruled out the presence of significant stenoses of the right coronary artery (treated with stents positioning) and the presence of an anomalous vessel arising from the proximal right coronary artery (panel A, black narrow), suspected for coronary artery fistula. Therefore a multidetector row computed tomographic (CT) scan was performed. The CT exam showed the presence of an anomalous, tortuous vessel arising from the aortic arch (at the usual site of the arterial ligament, panel B, white narrow), descending in front of the left pulmonary artery and draining into the
⁎ Corresponding author at: A.O. Ordine Mauriziano, Largo Turati 62, 10128 Torino, Italy. Tel.: +39 0115085000; fax: +39 0115085001. E-mail address: [email protected] (C.V. Lario).
http://dx.doi.org/10.1016/j.ijcard.2014.07.059 0167-5273/© 2014 Elsevier Ireland Ltd. All rights reserved.
main pulmonary artery (panel B, black narrow and panel C, black narrow). This vessel (aorto-pulmonary fistula) was characterized by the presence of two saccular aneurysms along its course (panel F: black asterisks). CT also demonstrated the presence of three vessels arising respectively from the right coronary artery (panel D, black narrow, the vessel is the same of the one showed in the coronary angiography, panel A), the left anterior descending artery and the circumflex coronary artery (panel E), dividing into smaller vessels all draining into the aortopulmonary fistula (Fig. 1). No other cardiac anomalies were observed and no significant right chamber dilatation was present. However patient hemodynamic studies revealed a systemic-to-right shunt flow ratio of 1.8. Surgical intervention would be required because of significant left-to-right shunt and the presence of saccular aneurysms along the aortopulmonary fistula but the patient, asymptomatic, refused it. Aortopulmonary artery fistula is a rare congenital condition but the peculiarity of this case is the association with coronary arteries-to-main pulmonary artery fistulas that has been described only a few times before. CT must be considered the reference imaging for evaluation of complex congenital vascular anomalies like the one we described according to its high spatial resolution. Conflict of interest No conflict of interest.
e48
C.V. Lario et al. / International Journal of Cardiology 176 (2014) e47–e48
Fig. 1. (A) coronary angiography shows the presence of an anomalous vessel arising from the proximal right coronary artery; (B) Volume rendering image of CT coronary angiography shows the presence of an anomalous, tortuous vessel arising from the aortic arch (white narrow) and draining into the main pulmonary artery (black narrow); (C) CT coronary angiography shows the drainage of the anomalous vessel into the main pulmonary artery (black narrow); (D) Volume rendering image of CT coronary angiography shows the right coronary artery fistula and (E) the circumflex coronary artery fistula; (F) Volume rendering image of CT coronary angiography shows saccular aneurysms along the aorto-to-pulmonary artery fistula course.
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
A rare case of aorto-to-pulmonary artery fistula associated with three coronary arteries-to-pulmonary artery fistulas Chiara Valentina Lario a,⁎, Annalisa Balbo Mussetto a, Teresa Gallo a, Barbara Mabritto b, Margherita Castiglione Morelli c, Maria Rosa Conte b, Stefano Cirillo a a b c
Department of Radiology, A.O. Ordine Mauriziano, Torino, Italy Department of Cardiology, A.O. Ordine Mauriziano, Torino, Italy Department of Radiology, IRCCS A.O. U. San Martino — IST, Genova, Italy
a r t i c l e
i n f o
Article history: Received 19 May 2014 Accepted 5 July 2014 Available online 22 July 2014 Keywords: Cardiac CT Coronary arteries-to-main pulmonary fistulas Aorto-to-main pulmonary fistula
We report the case of a rare congenital aorto-pulmonary artery fistula combined with coronary artery fistulas. A 72 year-old man was admitted to our hospital due to chest pain and dyspnoea. ECG showed an ST elevation and serological parameters confirmed the diagnosis of acute coronary artery syndrome. Coronary angiography ruled out the presence of significant stenoses of the right coronary artery (treated with stents positioning) and the presence of an anomalous vessel arising from the proximal right coronary artery (panel A, black narrow), suspected for coronary artery fistula. Therefore a multidetector row computed tomographic (CT) scan was performed. The CT exam showed the presence of an anomalous, tortuous vessel arising from the aortic arch (at the usual site of the arterial ligament, panel B, white narrow), descending in front of the left pulmonary artery and draining into the
⁎ Corresponding author at: A.O. Ordine Mauriziano, Largo Turati 62, 10128 Torino, Italy. Tel.: +39 0115085000; fax: +39 0115085001. E-mail address: [email protected] (C.V. Lario).
http://dx.doi.org/10.1016/j.ijcard.2014.07.059 0167-5273/© 2014 Elsevier Ireland Ltd. All rights reserved.
main pulmonary artery (panel B, black narrow and panel C, black narrow). This vessel (aorto-pulmonary fistula) was characterized by the presence of two saccular aneurysms along its course (panel F: black asterisks). CT also demonstrated the presence of three vessels arising respectively from the right coronary artery (panel D, black narrow, the vessel is the same of the one showed in the coronary angiography, panel A), the left anterior descending artery and the circumflex coronary artery (panel E), dividing into smaller vessels all draining into the aortopulmonary fistula (Fig. 1). No other cardiac anomalies were observed and no significant right chamber dilatation was present. However patient hemodynamic studies revealed a systemic-to-right shunt flow ratio of 1.8. Surgical intervention would be required because of significant left-to-right shunt and the presence of saccular aneurysms along the aortopulmonary fistula but the patient, asymptomatic, refused it. Aortopulmonary artery fistula is a rare congenital condition but the peculiarity of this case is the association with coronary arteries-to-main pulmonary artery fistulas that has been described only a few times before. CT must be considered the reference imaging for evaluation of complex congenital vascular anomalies like the one we described according to its high spatial resolution. Conflict of interest No conflict of interest.
e48
C.V. Lario et al. / International Journal of Cardiology 176 (2014) e47–e48
Fig. 1. (A) coronary angiography shows the presence of an anomalous vessel arising from the proximal right coronary artery; (B) Volume rendering image of CT coronary angiography shows the presence of an anomalous, tortuous vessel arising from the aortic arch (white narrow) and draining into the main pulmonary artery (black narrow); (C) CT coronary angiography shows the drainage of the anomalous vessel into the main pulmonary artery (black narrow); (D) Volume rendering image of CT coronary angiography shows the right coronary artery fistula and (E) the circumflex coronary artery fistula; (F) Volume rendering image of CT coronary angiography shows saccular aneurysms along the aorto-to-pulmonary artery fistula course.