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Sudden death in a patient with multiple left anterior descending coronary artery fistulas to the left ventricle
International Journal of Cardiology 125 (2008) e37 – e39 www.elsevier.com/locate/ijcard
Letter to the Editor
Sudden death in a patient with multiple left anterior descending coronary artery fistulas to the left ventricle Inigo Lozano⁎, Alberto Batalla, Jose Rubin, Pablo Avanzas, Maria Martin, Cesar Moris Hospital Central Asturias, Department of Cardiology, 2132 Piles-Infanzon, 33203, Gijon, Asturias, Spain Received 4 November 2006; accepted 25 November 2006 Available online 28 March 2007
Abstract Coronary fistulas to cardiac chambers are an infrequent anomaly and usually are found casually. Although the majority of patients are asymptomatic, in rare cases it may cause coronary steal and cardiac ischemia. We present a patient with a left anterior descending coronary artery with multiple small fistulas to the left ventricle that suffered angina and an episode of ventricular fibrillation that required electrical cardioversion and an intracardiac defibrillator. © 2007 Elsevier Ireland Ltd. All rights reserved. Keywords: Fistula; Ventricular fibrillation; Sudden death; Myocardial ischemia
1. Case report Coronary fistulas to cardiac chambers are a rare phenomenon and usually are casual findings [1]. However, occasionally they may develop coronary steal [2] causing angina [3], dyspnoea [3], myocardial infarction [4] or even sudden death [5]. We present a patient with multiple small fistulas from the left anterior descending coronary artery to the left ventricle that suffered unstable angina and an episode of sudden death, requiring finally an intracardiac defibrillator. A 54-years-old male with previous history of hypercholesterolemia was admitted with unstable angina and ECG changes in anterior leads (Fig. 1.1–1.2). A cardiac catheterization revealed absence of atherosclerotic disease and multiple small fistulas from the left anterior descending coronary artery to the left ventricle, with normal systolic function (Fig. 2). He was discharged on betablockers and aspirin without in-hospital events. Three months later he presented another episode of chest pain while he was working and he was transferred to the emergency room. Some minutes after admission he suffered an episode of ventricular fibrillation that was successfully ⁎ Corresponding author. E-mail address: [email protected] (I. Lozano). 0167-5273/$ - see front matter © 2007 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2006.11.247
cardioverted (Fig. 1.3–1.4). The cardiac catheterization was repeated with identical result than the first one. Surgical or percutaneous correction with coils were contemplated, but finally discouraged due to the multiple character and the small diameter of the connections. An intracardiac cardioverter defibrillator was implanted to prevent subsequent episodes of cardiac death. The patient was discharged uneventfully and one year later he continues on betablocker therapy with episodes of chest pain but with no new events in the defibrillator registry. Coronary fistulas to cardiac chambers are unusual findings and in most cases have a benign course [1]. The majority of patients are asymptomatic but in some cases they may cause coronary steal [2]. The most frequent symptoms are dyspnoea and angina [3], but may present as endocarditis [6], myocardial infarction [4] or cardiac death [5]. The right coronary artery usually is the vessel more often involved, but in some reports the left anterior descending is the predominant vessel and more than one artery may be affected [3]. There have been described diagnosis by echocardiography [7], but the coronary angiography is the method for detection. The anatomic defect may be corrected by surgical technique [8] or percutaneously with coils [9]. In a series of 14 patients described by Liu [3], 6 of them were treated surgically. One of them died in the postoperative period due to acute bronchitis. The other 5 are asymptomatic
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I. Lozano et al. / International Journal of Cardiology 125 (2008) e37–e39
Fig. 1. 1: Baseline ECG; 2: ECG in anterior leads; 3: Ventricular fibrillation. 4: Successful cardioversion.
five years after surgery. In the 8 remaining cases, after 5 years of follow-up, 4 of them continued with the initial clinical status and the other 4 registered progression of symptoms. To date, only one case of coronary fistula to cardiac chambers and sudden death has been described. It occurred in a young Chinese patient who suffered a sudden death and it was found in the necropsy a fistula of the right coronary artery to a markedly hypertrophied left ventricle with microscopic evidence of myocardial ischemia [5]. In the case we present, it was documented myocardial ischemia in the electrocardiogram and the patient suffered a ventricular fibrillation. As far as we know, this is the first case of documented ventricular fibrillation secondary to ischemia due to a coronary fistula to a cardiac chamber and the first case that required a cardioverter defibrillator. References
Fig. 2. Left anterior descending coronary artery fistula to left ventricle.
[1] Claeys M, Ranquin R, Van Den HP. Microfistulas from the left anterior interventricular coronary artery percolating the ventricular septum. Int J Cardiol 1991;30(2):227–8. [2] Kiuchi K, Nejima J, Kikuchi A, Takayama M, Takano T, Hayakawa H. Left coronary artery-left ventricular fistula with acute myocardial infarction, representing the coronary steal phenomenon: a case report. J Cardiol 1999;34(5):279–84.
I. Lozano et al. / International Journal of Cardiology 125 (2008) e37–e39 [3] Liu PR, Leong KH, Lee PC, Chen YT. Congenital coronary arterycardiac chamber fistulae: a study of fourteen cases. Zhonghua Yi Xue Za Zhi (Taipei) 1994;54(3):160–5. [4] McLellan BA, Pelikan PC. Myocardial infarction due to multiple coronary-ventricular fistulas. Cathet Cardiovasc Diagn 1989;16(4):247–9. [5] Lau G. Sudden death arising from a congenital coronary artery fistula. Forensic Sci Int 1995;73(2):125–30. [6] Lin YH, Chao CL, Lee YT, Chen SJ, Wang SS. Coronary artery fistula presented as infective endocarditis with pulmonary septic emboli. Int J Cardiol 2005;98(1):159–60.
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[7] Vitarelli A, De Curtis G, Conde Y, et al. Assessment of congenital coronary artery fistulas by transesophageal color Doppler echocardiography. Am J Med 2002;113(2):127–33. [8] Satoh H, Kazui T, Watanabe A, Yamamoto N, Yamaguchi T, Komatsu S. Symbas's operation in a case of congenital fistula of the right coronary artery to left ventricle. Kyobu Geka 1994;47(2):145–8. [9] Ragnarsson A, Emanuelsson H. Treatment of a large congenital coronary fistula with coil embolization. Scand Cardiovasc J 1999;33(1):57–9.
Letter to the Editor
Sudden death in a patient with multiple left anterior descending coronary artery fistulas to the left ventricle Inigo Lozano⁎, Alberto Batalla, Jose Rubin, Pablo Avanzas, Maria Martin, Cesar Moris Hospital Central Asturias, Department of Cardiology, 2132 Piles-Infanzon, 33203, Gijon, Asturias, Spain Received 4 November 2006; accepted 25 November 2006 Available online 28 March 2007
Abstract Coronary fistulas to cardiac chambers are an infrequent anomaly and usually are found casually. Although the majority of patients are asymptomatic, in rare cases it may cause coronary steal and cardiac ischemia. We present a patient with a left anterior descending coronary artery with multiple small fistulas to the left ventricle that suffered angina and an episode of ventricular fibrillation that required electrical cardioversion and an intracardiac defibrillator. © 2007 Elsevier Ireland Ltd. All rights reserved. Keywords: Fistula; Ventricular fibrillation; Sudden death; Myocardial ischemia
1. Case report Coronary fistulas to cardiac chambers are a rare phenomenon and usually are casual findings [1]. However, occasionally they may develop coronary steal [2] causing angina [3], dyspnoea [3], myocardial infarction [4] or even sudden death [5]. We present a patient with multiple small fistulas from the left anterior descending coronary artery to the left ventricle that suffered unstable angina and an episode of sudden death, requiring finally an intracardiac defibrillator. A 54-years-old male with previous history of hypercholesterolemia was admitted with unstable angina and ECG changes in anterior leads (Fig. 1.1–1.2). A cardiac catheterization revealed absence of atherosclerotic disease and multiple small fistulas from the left anterior descending coronary artery to the left ventricle, with normal systolic function (Fig. 2). He was discharged on betablockers and aspirin without in-hospital events. Three months later he presented another episode of chest pain while he was working and he was transferred to the emergency room. Some minutes after admission he suffered an episode of ventricular fibrillation that was successfully ⁎ Corresponding author. E-mail address: [email protected] (I. Lozano). 0167-5273/$ - see front matter © 2007 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2006.11.247
cardioverted (Fig. 1.3–1.4). The cardiac catheterization was repeated with identical result than the first one. Surgical or percutaneous correction with coils were contemplated, but finally discouraged due to the multiple character and the small diameter of the connections. An intracardiac cardioverter defibrillator was implanted to prevent subsequent episodes of cardiac death. The patient was discharged uneventfully and one year later he continues on betablocker therapy with episodes of chest pain but with no new events in the defibrillator registry. Coronary fistulas to cardiac chambers are unusual findings and in most cases have a benign course [1]. The majority of patients are asymptomatic but in some cases they may cause coronary steal [2]. The most frequent symptoms are dyspnoea and angina [3], but may present as endocarditis [6], myocardial infarction [4] or cardiac death [5]. The right coronary artery usually is the vessel more often involved, but in some reports the left anterior descending is the predominant vessel and more than one artery may be affected [3]. There have been described diagnosis by echocardiography [7], but the coronary angiography is the method for detection. The anatomic defect may be corrected by surgical technique [8] or percutaneously with coils [9]. In a series of 14 patients described by Liu [3], 6 of them were treated surgically. One of them died in the postoperative period due to acute bronchitis. The other 5 are asymptomatic
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I. Lozano et al. / International Journal of Cardiology 125 (2008) e37–e39
Fig. 1. 1: Baseline ECG; 2: ECG in anterior leads; 3: Ventricular fibrillation. 4: Successful cardioversion.
five years after surgery. In the 8 remaining cases, after 5 years of follow-up, 4 of them continued with the initial clinical status and the other 4 registered progression of symptoms. To date, only one case of coronary fistula to cardiac chambers and sudden death has been described. It occurred in a young Chinese patient who suffered a sudden death and it was found in the necropsy a fistula of the right coronary artery to a markedly hypertrophied left ventricle with microscopic evidence of myocardial ischemia [5]. In the case we present, it was documented myocardial ischemia in the electrocardiogram and the patient suffered a ventricular fibrillation. As far as we know, this is the first case of documented ventricular fibrillation secondary to ischemia due to a coronary fistula to a cardiac chamber and the first case that required a cardioverter defibrillator. References
Fig. 2. Left anterior descending coronary artery fistula to left ventricle.
[1] Claeys M, Ranquin R, Van Den HP. Microfistulas from the left anterior interventricular coronary artery percolating the ventricular septum. Int J Cardiol 1991;30(2):227–8. [2] Kiuchi K, Nejima J, Kikuchi A, Takayama M, Takano T, Hayakawa H. Left coronary artery-left ventricular fistula with acute myocardial infarction, representing the coronary steal phenomenon: a case report. J Cardiol 1999;34(5):279–84.
I. Lozano et al. / International Journal of Cardiology 125 (2008) e37–e39 [3] Liu PR, Leong KH, Lee PC, Chen YT. Congenital coronary arterycardiac chamber fistulae: a study of fourteen cases. Zhonghua Yi Xue Za Zhi (Taipei) 1994;54(3):160–5. [4] McLellan BA, Pelikan PC. Myocardial infarction due to multiple coronary-ventricular fistulas. Cathet Cardiovasc Diagn 1989;16(4):247–9. [5] Lau G. Sudden death arising from a congenital coronary artery fistula. Forensic Sci Int 1995;73(2):125–30. [6] Lin YH, Chao CL, Lee YT, Chen SJ, Wang SS. Coronary artery fistula presented as infective endocarditis with pulmonary septic emboli. Int J Cardiol 2005;98(1):159–60.
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[7] Vitarelli A, De Curtis G, Conde Y, et al. Assessment of congenital coronary artery fistulas by transesophageal color Doppler echocardiography. Am J Med 2002;113(2):127–33. [8] Satoh H, Kazui T, Watanabe A, Yamamoto N, Yamaguchi T, Komatsu S. Symbas's operation in a case of congenital fistula of the right coronary artery to left ventricle. Kyobu Geka 1994;47(2):145–8. [9] Ragnarsson A, Emanuelsson H. Treatment of a large congenital coronary fistula with coil embolization. Scand Cardiovasc J 1999;33(1):57–9.