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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Congenital coronary artery fistula &#40;CAF&#41; is defined as a direct communication between a coronary artery and any cardiac chamber or vessel&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Although rare&#44; they are the most common hemodynamically significant congenital coronary artery anomaly&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> Patients may be asymptomatic&#44; but may also present with symptoms such as angina&#44; exertional dyspnea&#44; fatigue&#44; or heart failure depending on the hemodynamic significance of the fistula&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Transcatheter embolization has been an increasingly popular treatment following the first fistula occlusion by Reidy et al&#46; in 1983&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Following reports in the literature&#44; we present a successful transcatheter occlusion of a giant fistula by coil embolization in a patient who presented to our outpatient clinic with complaints of exertional dyspnea&#44; chest pain&#44; fatigue&#44; and paroxysmal palpitations&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0010" class="elsevierStylePara elsevierViewall">A 49-year-old woman was admitted to our outpatient clinic with complaints of exertional dyspnea&#44; exertional chest pain&#44; paroxysmal palpitation attacks&#44; and fatigue&#46; She had been treated for diabetes for two years but had no additional risk factors for coronary artery disease&#46; On physical examination&#44; her blood pressure was 130&#47;80 mmHg and heart rate 85 bpm&#46; No pathological sounds were heard during pulmonary and cardiac auscultation&#46; Routine biochemical and hemogram values were within normal ranges&#46; Ejection fraction was 60&#37;&#44; and no serious valve disease was detected on transthoracic echocardiography&#46; Electrocardiography showed sinus rhythm&#46; Right atrial tachycardia was induced with programmed atrial stimulation during a diagnostic electrophysiologic study &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46; Coronary angiography was also performed in order to clarify potential ischemic etiology&#46; While the left coronary and right coronary arteries were found to be normal&#44; a giant fistula was detected from the proximal portion of the right coronary artery to the right atrium &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>&#41;&#46; Qp&#47;Qs was 1&#58;1 by oximetry and all right heart pressures were within normal ranges during right heart catheterization&#46; Computed tomography &#40;CT&#41; angiography was also conducted for a detailed anatomical assessment&#44; which showed a fistulized artery about 8 mm in diameter originating from the right coronary artery 2 cm distal to the orifice and draining into the intersection of the inferior vena cava and right atrium after following a tortuous course &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>&#41;&#46; The patient&#39;s symptoms were considered to be related to a coronary steal phenomenon in addition to the arteriovenous shunt caused by such a large fistula&#46; A percutaneous occlusion procedure was preferred for the patient&#39;s comfort and to avoid complications likely to be caused by surgery&#46; During the procedure&#44; a Judkins guiding catheter was placed in the right coronary artery ostium and the fistulized artery was selectively catheterized via microcatheter&#44; then multiple coils with different sizes ranging from 9 mm to 3 mm were sequentially placed in a suitable location in the mid portion of the fistulized artery until total occlusion was achieved &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Figure 4</a>&#41;&#46; The patient&#39;s atrial tachycardia could not be induced again during the control electrophysiologic study repeated at the end of one month&#46; Finally&#44; progressive improvement was observed in exertional capacity&#44; and other symptoms including paroxysmal palpitations completely disappeared during follow-up&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0015" class="elsevierStylePara elsevierViewall">Congenital CAF is defined as the presence of a direct communication between a coronary artery and any cardiac chamber or vessel&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Although rare&#44; they are the most common hemodynamically significant congenital coronary artery anomaly&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> Fistulized arteries may be open to either the systemic or the pulmonary circulation&#46; They may be congenital or acquired&#46; The pathophysiological mechanism in congenital CAF is described as continuance of the sinusoidal connections which maintain myocardial blood flow in the early embryological period&#46; Acquired CAF may be caused by cardiac trauma&#44; surgery&#44; percutaneous intervention or pacemaker installation&#44; or be secondary to inflammation&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> In their series of 126<span class="elsevierStyleHsp" style=""></span>595 cases of patients undergoing coronary angiography&#44; Yamanaka and Hobbs reported an incidence of coronary artery anomalies of 1&#46;3&#37;&#44; while that of CAF was 0&#46;18&#37; &#40;13&#37; of all coronary artery anomalies&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Fistulized arteries&#44; originating in the right coronary artery or its branches&#44; comprise 50&#8211;55&#37; of all CAFS&#46; In terms of the structures with which coronary fistulas are connected&#44; 40&#37; are fistulized to the right ventricle&#44; 25&#37; to the right atrium&#44; 15&#8211;20&#37; to the pulmonary artery&#44; and 7&#37; to the coronary sinus&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> In our case&#44; a giant fistula was detected originating in the proximal right coronary artery and draining into the intersection of the inferior vena cava and the right atrium&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">CAFs do not give rise to symptoms or complications in most cases&#44; and so most are detected either incidentally during coronary angiography or in the course of examinations to clarify a cardiac murmur&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Small CAFs are generally asymptomatic and rarely expand&#44; and may close spontaneously&#44; especially those that open into the right ventricle&#46; On the other hand&#44; large fistulas tend to continue to expand&#44; and despite not causing any symptoms in the first two decades of life&#44; symptoms and complications may develop with age&#44;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;6</span></a> including heart failure&#44; myocardial ischemia and angina&#44; infective endocarditis&#44; and atrial fibrillation&#46; Myocardial ischemia and angina may develop in large fistulas due to a coronary steal phenomenon&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Angina has been reported in 7&#37; of cases&#44; myocardial infarction in 3&#37;&#44; and heart failure in 12&#8211;15&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Fistula-related mortality is correlated with surgical intervention&#44; and has been reported as occurring in 0&#8211;4&#37; of cases&#46; The surgical mortality risk is higher in large aneurysmal fistulas and in those originating in the right coronary artery and draining into the left ventricle than in other cases&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> No association between CAFs and atrial tachycardia has so far been indicated in the literature&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Atrial tachycardia is a type of supraventricular tachycardia that originates from a focus in either of the two atria with a heart rate of &#62;100 bpm&#46; The symptoms of atrial tachycardia are similar to those of other supraventricular tachycardias&#58; palpitations&#44; lightheadedness&#44; dizziness&#44; shortness of breath&#44; reduced exercise capacity&#44; weakness&#44; fatigue&#44; chest discomfort&#44; and sweating episodes&#46; Atrial tachycardia is seen in patients both with and without structural heart disease&#46; It can originate from virtually any focus in the left or right atrium&#46; Therapy for patients suffering from atrial tachycardia depends on the frequency and severity of symptoms and includes either medical management or curative catheter ablation&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">CAF can be diagnosed by means of the physical examination findings in asymptomatic patients&#46; The point where the continuous murmur related to the CAF is loudest may vary depending on the fistula&#39;s entry site into the heart&#46; While those that end in the right atrium cause a murmur at the lower sternal border&#44; in those ending in the pulmonary artery a murmur is heard at the second intercostal space&#44; and in those ending in the left ventricle the murmur may be near the apex&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> In the case presented&#44; no pathological sounds were heard during cardiac auscultation&#46; However&#44; the nature of the patient&#39;s paroxysmal palpitations was characteristic of a supraventricular tachycardia&#44; so we immediately decided to perform a diagnostic electrophysiologic study&#46; Additionally&#44; the patient&#39;s history of diabetes&#44; exertional angina&#44; and other symptoms of heart failure prompted suspicions in this case concerning an ischemic etiology&#44; which prompted us to perform coronary angiography as well&#46; Although this is the gold standard for imaging the coronary arteries&#44; it may be insufficient to assess the fistula&#39;s relation with nearby anatomical structures&#46; CT provides detailed information on the origin and drainage sites&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> For this reason&#44; our patient also underwent CT angiography after the fistula was diagnosed by coronary angiography&#46; Right heart catheterization was also performed to assess the fistula&#39;s hemodynamic significance&#59; the normal right heart catheterization findings were considered to be due to the fact the fistula drained into the intersection of the inferior vena cava and right atrium&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Unless small and asymptomatic&#44; CAFs should be corrected due to the increased risk of thrombosis&#44; endocarditis&#44; rupture&#44; and heart failure&#46; Asymptomatic cases require close follow-up by echocardiography or angiography&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;7</span></a> Treatment options include transcatheter occlusion and surgery&#46; Described for the first time by Reidy et al&#46; in 1983&#44; transcatheter occlusion is increasingly used&#44;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> although tortuous and extra-large fistulas with more than one opening and with serious aneurysmal dilatations are not suitable for a transcatheter approach&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Transcatheter coil implantation is the method of choice in suitable cases&#46; Complications of the transcatheter approach are related to the catheter and guidewire manipulation&#44; as well as coil placement in an unsuitable location or embolization&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> However&#44; the transcatheter approach is superior to surgery in that it increases patient comfort and avoids surgical complications&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> However&#44; in cases unsuitable for a transcatheter approach&#44; surgical treatment is an option&#44; involving median sternotomy and cardiopulmonary bypass&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;8</span></a> Risk of post-surgical myocardial infarction is reported as 3&#37;&#44; mortality 2&#8211;2&#46;4&#37;&#44; and fistula recurrence 4&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> With increasing experience and technical advances&#44; transcatheter occlusion has become a successful method&#46; Its reliability and effectiveness are equal to those of surgery&#44; and it is thus preferable in most cases with a hemodynamically important fistula&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;8</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">In our patient&#44; it was decided to intervene due to the presence of severe symptoms associated with coronary steal and high-output heart failure&#44; and we opted for transcatheter coil embolization after assessing the suitability of the fistulized artery&#39;s anatomical features for the procedure&#46; The fistula was successfully occluded by transcatheter coil embolization&#44; with no complications&#46; Although right atrial tachycardia&#44; to which most of the patient&#39;s symptoms can be attributed&#44; was induced during an electrophysiologic study&#44; we suspected concomitant coronary artery disease&#46; We therefore performed coronary angiography before deciding on any treatment for atrial tachycardia&#46; After detecting a giant right coronary fistula and excluding coronary artery disease&#44; we hypothesized that the patient&#39;s atrial tachycardia might have been caused by this fistula&#44; so we opted to treat it first and treat the atrial tachycardia later&#46; The tachycardia could not be induced again during the control electrophysiologic study repeated after one month&#59; the patient stated that her symptoms&#44; including paroxysmal palpitations&#44; had completely disappeared&#44; and her exertional capacity was also substantially improved during the follow-up period&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">All CAFs that cause hemodynamic compromise or serious symptoms require intervention&#46; Although CAF is rarely seen&#44; it should be borne in mind that atrial tachycardia may be associated with CAFs&#44; especially those draining into the atria&#46; Therefore&#44; vascular disorders such as CAF should be considered before specifically treating these arrhythmias&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Ethical disclosures</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Protection of human and animal subjects</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Confidentiality of data</span><p id="par0055" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Right to privacy and informed consent</span><p id="par0060" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conflicts of interest</span><p id="par0180" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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          "titulo" => "Introduction"
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          "titulo" => "Ethical disclosures"
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              "identificador" => "sec0025"
              "titulo" => "Protection of human and animal subjects"
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              "identificador" => "sec0035"
              "titulo" => "Right to privacy and informed consent"
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    "fechaRecibido" => "2013-12-25"
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          "clase" => "keyword"
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            0 => "Coronary artery fistula"
            1 => "Atrial tachycardia"
            2 => "Coil embolization"
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            0 => "Fistula arterial coron&#225;ria"
            1 => "Taquicardia auricular"
            2 => "Emboliza&#231;&#227;o com coil"
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        "titulo" => "Abstract"
        "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Coronary artery fistulas are the second most frequently seen coronary anomaly following abnormalities of coronary artery origin and distribution&#46; A coronary fistula is defined as a direct communication between a coronary artery and any cardiac chamber or vessel&#46; Treatment options include percutaneous embolization and surgical intervention&#46; Herein&#44; we present a case of a giant coronary artery fistula and right atrial tachycardia that was induced during a diagnostic electrophysiologic study but was not inducible after the successful treatment of the fistula&#46; This is the first case indicating this association&#46;</p>"
      ]
      "pt" => array:2 [
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        "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">As f&#237;stulas coron&#225;rias s&#227;o a segunda anomalia mais frequente das art&#233;rias coron&#225;rias a seguir &#224;s anomalias coron&#225;rias da c&#226;mara de sa&#237;da&#46; A f&#237;stula define-se como uma comunica&#231;&#227;o direta entre as art&#233;rias coron&#225;rias e uma cavidade card&#237;aca ou estrutura vascular&#46; As op&#231;&#245;es terap&#234;uticas incluem a emboliza&#231;&#227;o percut&#226;nea e o tratamento cir&#250;rgico&#46; Apresentamos aqui um caso de uma fistula coron&#225;ria gigante e taquicardia auricular direita induzida durante um estudo electrofisiol&#243;gico diagn&#243;stico e que n&#227;o foi poss&#237;vel induzir ap&#243;s o tratamento bem sucedido da f&#237;stula&#46; Este &#233; o primeiro caso que reporta esta associa&#231;&#227;o&#46;</p>"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Electrocardiographic tracings during sinus rhythm &#40;A&#41; and atrial tachycardia &#40;B&#41;&#46; Variability of ventricular activity duration and the first atrial activity seen on proximal coronary sinus recordings indicate left atrial tachycardia &#40;B&#41;&#46; Recording speed 150 mm&#47;s&#44; tachycardia cycle length 420 ms&#46;</p>"
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">A giant coronary fistula originating from the proximal portion of the right coronary artery and draining into the right atrium&#44; seen on the angiogram&#44; left anterior oblique cranial view&#46;</p>"
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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">A fistulized artery originating from the right coronary artery 2 cm distal to the orifice and draining into the inferior vena cava at the intersection with the proximal atrium after following a tortuous course&#44; as demonstrated by reformatted three-dimensional volume rendered computed tomography angiographic imaging&#46;</p>"
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          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Total occlusion of the fistula before the proximal coil &#40;arrow&#41; seen on the control angiogram&#44; left anterior oblique cranial view&#46;</p>"
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