Sirs:Coronary artery fistulas are anomalous connections between a coronary artery and a cardiac chamber or great vessel [1]. They are rare abnormalities with a reported incidence of 0.13-0.18% of patients undergoing coronary angiography [2,3]. The majority of coronary artery fistulas are congenital in origin, but they have been reported as acquired complications of chest trauma and surgery also. Most of them are diagnosed incidentally in asymptomatic patients, but depending on shunt volume, congestive heart failure can develop [1]. Furthermore, myocardial ischemia due to a 'steal' from the adjacent myocardium has been reported [4][5][6][7][8][9][10][11][12], but true existence of this phenomenon is a controversial issue [13]. We present the case of a young female with a large coronary artery fistula originating from the proximal left anterior descending artery (LAD), and evidence of a coronary steal syndrome is provided by fractional flow reserve (FFR).A so far healthy 36-year-old female without cardiovascular risk factors presented in our emergency department with sudden onset chest pain following a long exhausting motorbike trip. Physical examination was unremarkable, and no cardiac murmur was audible. Baseline electrocardiogram showed T inversions in the anterior leads, and the cardiac biomarkers were elevated with a peak high sensitive Troponin T of 0.55 lg/l and a peak creatine kinase of 623 U/l. Subsequent left heart catheterization ruled out coronary artery disease, but a large coronary artery fistula originating from the proximal LAD draining into to the pulmonary trunk was found (Fig. 1). Ventriculography showed a hypokinesis of the anterior segments distal to the origin of the fistula, and magnetic resonance tomography revealed a late enhancement pattern of subendocardial myocardial infarction (Fig. 2). Hypothesizing a coronary steal syndrome due to the fistula, a second procedure with left and right heart catheterization was performed. Hemodynamic and oximetric measurements revealed a systemic blood flow (Q S ) of 6.0 l/min and a pulmonary blood flow (Q P ) of 6.7 l/min, leading to a relatively small calculated left-to-right shunt of 0.68 l/min (Q P /Q S = 1.12), and pulmonary artery pressure was in normal range. FFR in the distal LAD was 0.78 under maximal hyperemia, raising to 0.95 while temporary experimental occlusion of the fistula using a 3.0/15 mm standard balloon catheter. In consideration of this evidence of steal syndrome, coil embolization of the fistula was performed in the same procedure, using 2 Detach TM embolization coils (Cook Medical, Bloomington, IN, USA) [2-2 and 2-4 (diameter in mm-length in cm)] in each of the two main branches and another two coils (3-4 and 3-6) in the bifurcation of the fistula (Fig. 1). Finally, a FFR of 1.0 was measured in the distal LAD. The patient was discharged free of symptoms the following day. At 3-month follow-up, the patient was free of symptoms, and echocardiography revealed complete recovery of left ventricular function.A coronary artery fistula is ...

Hydrostatic pressure variations resulting from normal coronary anatomy in a supine position influence intracoronary pressure measurements and may affect their interpretation during stenosis severity assessment.

No abstract

Looking after children means caring for very small infants up to adult-sized adolescents, with weights ranging from 500 g to more than 100 kg and heights ranging from 25 to more than 200 cm. The available echocardiographic reference data were drawn from a small sample, which did not include preterm infants. Most authors have used body weight or body surface area to predict left ventricular dimensions. The current authors had the impression that body length would be a better surrogate parameter than body weight or body surface area. They analyzed their echocardiographic database retrospectively. The analysis included all available echocardiographic data from 6 June 2001 to 15 December 2011 from their echocardiographic database. The authors included 12,086 of 26,325 subjects documented as patients with normal hearts in their analysis by the examining the pediatric cardiologist. For their analysis, they selected body weight, length, age, and aortic and pulmonary valve diameter in two-dimensional echocardiography and left ventricular dimension in M-mode. They found good correlation between echocardiographic dimensions and body surface area, body weight, and body length. The analysis showed a complex relationship between echocardiographic measurements and body weight and body surface area, whereas body length showed a linear relationship. This makes prediction of echo parameters more reliable. According to this retrospective analysis, body length is a better parameter for evaluating echocardiographic measurements than body weight or body surface area and should therefore be used in daily practice.

We describe 3 patients with severe aortic regurgitation after aortic root replacement using the Freestyle bioprosthesis (Medtronic, Minneapolis, MN). The indication in 2 patients was endocarditis. The third patient showed rupture of the right coronary cusp. To achieve fewer complications, lower operative risk, and reduce operative and cross-clamp times, implantation of a sutureless bioprosthesis in a valve-in-valve manner was performed. A Perceval bioprosthesis (Sorin Biomedica Cardio Srl, Sallugia, Italy) was used in 2 patients, and a 3F Enable bioprosthesis (Medtronic) was used in the other patient. No perioperative complications or in-hospital deaths were observed. We conclude that sutureless aortic valve prostheses offer a safe and feasible option for management of failed homografts.