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Left Coronary Artery Fistula After Septal Myectomy in Hypertrophic Cardiomyopathy
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Left Coronary Artery Fistula After Septal Myectomy in Hypertrophic Cardiomyopathy B.R. Gray, MB BS a,b,∗ , C. Semsarian, FRACP, FCSANZ, FAHA a,b,c , R.W. Sy, MBBS a and R.W. Jeremy, FRACP, FCSANZ a,b a c
Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia b Faculty of Medicine, University of Sydney, Australia Agnes Ginges Centre for Molecular Cardiology, Centenary Institute, Australia
A
41 year-old man presented with recurrent syncope. He had known hypertrophic cardiomyopathy and had undergone surgical septal myectomy overseas four months previously. On admission the ECG showed sinus rhythm with left bundle branch block, left ventricular hypertrophy and a prolonged corrected QT interval of 520 ms. Echocardiography showed residual asymmetric septal hypertrophy with the myectomy site easily identifiable. A left coronary artery fistula with diastolic flow was observed at the myectomy site (Fig. 1). Although no arrhythmias were documented, the patient was felt to be at high risk for sudden cardiac death due to unexplained syncope and an implantable cardioverter defibrillator was implanted. A follow up echocardiogram two months later showed persistence of the fistula at six months post myectomy. Left coronary artery fistulas have been reported following surgical myectomy. In one series Sgalambro et al. [1] reported 9 out of 40 (23%) patients had detectable left coronary artery fistulas at one month after myectomy, with one patient having multiple fistulas. Most healed spontaneously and at six months only 2 of 9 had persistent fistulas. The present case reminds us that iatrogenic left coronary artery fistulas are more common than generally realised but are usually benign.
Figure 1. Upper panel: Parasternal long-axis view showing myectomy site in basal septum. Lower panel: Parasternal short-axis view showing diastolic flow in coronary fistula.
Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at doi:10.1016/j.hlc.2011.06.001.
Received 1 March 2011; received in revised form 30 May 2011; accepted 2 June 2011; available online 6 July 2011
Reference [1] Sgalambro A, Olivotto I, Rossi A, Nistri S, Baldini K, Baldi M, et al. Prevalence and clinical significance of acquired left coronary artery fistulas after surgical myectomy in patients with hypertrophic cardiomyopathy. J Thorac Cardiovasc Surg 2010;140:1046–52.
∗
Corresponding author at: Department of Cardiology, Royal Prince Alfred Hospital, Missenden Rd., Camperdown, NSW 2050, Australia. Tel.: +61 407401432. E-mail address: [email protected] (B.R. Gray).
1443-9506/04/$36.00 doi:10.1016/j.hlc.2011.06.001
Image
Left Coronary Artery Fistula After Septal Myectomy in Hypertrophic Cardiomyopathy B.R. Gray, MB BS a,b,∗ , C. Semsarian, FRACP, FCSANZ, FAHA a,b,c , R.W. Sy, MBBS a and R.W. Jeremy, FRACP, FCSANZ a,b a c
Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia b Faculty of Medicine, University of Sydney, Australia Agnes Ginges Centre for Molecular Cardiology, Centenary Institute, Australia
A
41 year-old man presented with recurrent syncope. He had known hypertrophic cardiomyopathy and had undergone surgical septal myectomy overseas four months previously. On admission the ECG showed sinus rhythm with left bundle branch block, left ventricular hypertrophy and a prolonged corrected QT interval of 520 ms. Echocardiography showed residual asymmetric septal hypertrophy with the myectomy site easily identifiable. A left coronary artery fistula with diastolic flow was observed at the myectomy site (Fig. 1). Although no arrhythmias were documented, the patient was felt to be at high risk for sudden cardiac death due to unexplained syncope and an implantable cardioverter defibrillator was implanted. A follow up echocardiogram two months later showed persistence of the fistula at six months post myectomy. Left coronary artery fistulas have been reported following surgical myectomy. In one series Sgalambro et al. [1] reported 9 out of 40 (23%) patients had detectable left coronary artery fistulas at one month after myectomy, with one patient having multiple fistulas. Most healed spontaneously and at six months only 2 of 9 had persistent fistulas. The present case reminds us that iatrogenic left coronary artery fistulas are more common than generally realised but are usually benign.
Figure 1. Upper panel: Parasternal long-axis view showing myectomy site in basal septum. Lower panel: Parasternal short-axis view showing diastolic flow in coronary fistula.
Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at doi:10.1016/j.hlc.2011.06.001.
Received 1 March 2011; received in revised form 30 May 2011; accepted 2 June 2011; available online 6 July 2011
Reference [1] Sgalambro A, Olivotto I, Rossi A, Nistri S, Baldini K, Baldi M, et al. Prevalence and clinical significance of acquired left coronary artery fistulas after surgical myectomy in patients with hypertrophic cardiomyopathy. J Thorac Cardiovasc Surg 2010;140:1046–52.
∗
Corresponding author at: Department of Cardiology, Royal Prince Alfred Hospital, Missenden Rd., Camperdown, NSW 2050, Australia. Tel.: +61 407401432. E-mail address: [email protected] (B.R. Gray).
1443-9506/04/$36.00 doi:10.1016/j.hlc.2011.06.001