Coronary artery fistula in the heart transplant patient. A potential complication of endomyocardial biopsy.

Abstract

All follow-up annual cardiac catheterizations performed on recipients of orthotopic heart transplant were reviewed, and 14 patients with coronary artery fistula were identified. The prevalence (8.0%, 14 of 176 patients) was strikingly higher than that for patients without transplant (0.2%) who underwent routine cardiac catheterization. These 14 patients had 21 coronary artery fistulas: single in nine and multiple in five patients. Fifty-two percent arose from the right, 43% from the left anterior descending, and 5% from the circumflex coronary artery. All drained into the right ventricle. Four patients underwent oximetric evaluation, and left-to-right shunting was not detectable. No patient had symptoms attributable to the fistula. Hemodynamic measurements were similar to those of a control group of 28 age-and sex-matched recipients of heart transplant without coronary artery fistula; however, the cardiac index (p=0.02) and pulmonary artery oxygen saturation (p=0.03) were significantly higher, and the arteriovenous oxygen diflference (p=0.01) was significantly lower in the group with coronary artery fistula. The histologic features of rejection, large arterioles, or epicardial fat on any biopsy specimen predating coronary artery fistula diagnosis were not associated with the development of the fistula when the two groups were compared. Nine patients (11 coronary artery fistulas) had follow-up studies performed, and three fistulas were larger, three were unchanged, two were smaller, and three had resolved. No complications of coronary artery fistula developed during a mean follow-up of 28 months (range, 12-42 months). Based on the high prevalence of coronary artery fistulas in heart transplant patients and their uniform drainage into the right ventricle, we conclude that the fistulas are related to repeated endomyocardial biopsies. The lack of untoward events, the generally small size of the fistulas, and the occurrence of spontaneous resolution 1989;79:350-356) In the long-term management of recipients of orthotopic heart transplant, endomyocardial biopsy is the primary method of diagnosing tissue rejection. The immediate complications and relative safety of this procedure have been well described.1,2 This study documents the development of coronary artery fistula as a probable sequela to endomyocardial biopsy and characterizes the patient population in which it occurs.

Aneurysmal Coronary Artery Fistulae: How Big is Big Enough?

“…3,4 Although most remain asymptomatic during childhood and adolescence, many develop symptoms because of complications in adulthood. Aneurysm formation has been reported in around one in five cases.…”

Coronary artery‐right ventricular fistula after coronary artery bypass grafting

“…repeated endomyocardial biopsies postcardiac transplantation, 8 and not uncommonly as a result of neovascularization in an area of mural thrombosis such as in the left atrial appendage in patients with mitral stenosis, or in the left ventricle in patients with myocardial infarction or dilated canhomyopathy. "JO Newly formed blood vessels passing from the subendocardium to an organizing mural thrombus have been demonstrated in a pathological specimen by use of mimradiography.l' A coronary artery-left ventricular fistula has also been reported occur after a myocardial infarction not accompanied by mural thrombosis.…”

Fístula coronaria gigante. Presentación clínica, caracterización angiográfica, tratamiento y seguimiento a largo plazo: Caso clínico

“…ugaldehector@gmail.com L as anomalías de las arterias coronarias son de infrecuente presentación e incluyen variaciones en el origen, en su calibre, en su trayecto y en su lugar de finalización 1 . Dentro de ellas están las fístulas coronarias, que se definen como conexiones anormales entre una arteria coronaria y una cámara cardiaca o un vaso intraaórtico mayor, la mayor parte de ellas de origen congénito 2,3 , pero, en algunas ocasiones pueden ser adquiridas [4][5][6] . Su significación clínica no esta muy bien estudiada, se considera que la mayor parte de ellas no presentan síntomas, pero en algunos casos pueden ocasionar síntomas de isquemia o insuficiencia cardiaca 7 y también ser objeto de complicaciones como endocarditis bacteriana, disección, trombosis e infarto al miocardio 8,9 .…”