Abstract
INTRODUCTION
Coronary-cameral fistulas (CCF) are mostly congenital, rarely acquired malformations that create a communication between one or more coronary arteries and one of the cardiac chambers resulting in arterio-venous or arterio-arterial connections, giving rise to left-right or left-left shunts.
CASE REPORT
A 64 year-old man with history of heart transplant in September 2018 for severe post-ischemic heart failure, was transferred in our cardiology service after a three months cardiac reeducation program. The patient was to be discharged on the same day but the accidental discovery of a myocardial septo-apical infarction with ST segment elevation motivated his admission for urgent coronary angiography. The patient did not present any thoracic pain, only a slight numbness in his right shoulder. Troponin T value was 1735pg/ml. The coronary angiography showed a recent occlusion in the distal segment of the left anterior descending artery presenting with an aneurismal dilatation and CCF.
Further we completed the exam with a transthoracic echocardiography showing an akinetic apex in the presence of a fistula between the left anterior descending artery and the apex of the right ventricle with a high velocity flowing (Vmax = 1.8m/s) preferentially directional to the right ventricle.
Reviewing the medical history we found out that the patient had had a endomyocardial biopsy three days before this episode. Clinically a continuous cardiac murmur could be heard and the patient presented NYHA II dyspnea. Following this clinical presentation we decided to discuss the case within a heart team reunion and the decision taken was to place a covered stent in the distal segment of the left descending artery so as to permit the occlusion of the fistula. The evolution was favorable and the patient was discharged five days later.
DISCUSSION
Diagnosis of acquired CCF is suspected by clinical history and recurrence of symptoms, occurrence of a new continuous machinery cardiac murmur and a palpable thrill. Normally conservative medical management is sufficient to relieve symptoms in these acquired fistulas and spontaneous resolution is very common in CCF acquired following endomyocardial biopsy.
In our case report we noted the occurrence of a systolo-diastolic murmur following endomyocardial biopsy with a patient who was symptomatic of myocardial infraction. The literature describes report cases of symptomatic patients who needed a surgical or endovascular occlusion of the acquired CCF following endomyocardial biopsy by implanting a covered stent or with a covered balloon.
CONCLUSION
The termination site of acquired iatrogenic CCF following endomyocardial biopsy in the heart transplant population is usually the right ventricle with an elevated ratio of spontaneous resolution of this coronary-cameral communications. However in sysmptomatic patients a surgical or endo-vascular occlusion may be needed.
Abstract P633 Figure. Transthoracic echography findings
Obstructive teratoma in the right ventricle of a newborn: a case report
