Images in cardiology
Coronary artery fistula presenting as unstable angina
Fístula de artéria coronária apresentando-se como angina instável
Miguel Silva Vieira
, Nuno Antunes, Diana Anjo, Paulo Palma, Henrique Carvalho, Severo Torres
Autor para correspondência
Cardiology Department, Hospital Santo António, Centro Hospitalar do Porto, Porto, Portugal
Lido
9346
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Dobutamine stress echocardiography showed ischemia in the right coronary artery territory. Coronary angiography revealed no obstructive epicardial disease in the left dominant circulation (<a class="elsevierStyleCrossRef" href="#fig0030">Figure 2</a>A); the right coronary artery (RCA) was a small caliber and tortuous vessel, with only minor atheroma. However, an abnormal vessel arising from the proximal RCA was noted (<a class="elsevierStyleCrossRef" href="#fig0030">Figure 2</a>B and C), confirmed as a fistulous connection to the left atrium by multislice computed tomography, which also excluded other vascular anomalies (<a class="elsevierStyleCrossRef" href="#fig0035">Figure 3</a>). This was deemed to be causing a coronary steal phenomenon. Exercise myocardial perfusion imaging under anti-ischemic therapy excluded residual ischemia and the patient was successfully conservatively managed (<a class="elsevierStyleCrossRef" href="#fig0040">Figure 4</a>).</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><elsevierMultimedia ident="fig0030"></elsevierMultimedia><elsevierMultimedia ident="fig0035"></elsevierMultimedia><elsevierMultimedia ident="fig0040"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">Coronary-pulmonary artery fistulas (CPAF) are rare, often incidental findings of coronary angiography, thought to be remnants of a vascular connection from the mediastinal mesoderm. Coronary steal has been reported even in small fistulas, due to runoff to a low-pressure system, with reduction of intracoronary diastolic perfusion pressure. Treatment should be based on the presence of symptoms and anatomy (number and size, nature of feeding vessel, draining site, quantification of myocardium at risk of ischemia and shunt), with catheter and surgical options being offered if technically feasible.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Given the fistula's small size, from a non-dominant coronary artery, and in the absence of right ventricular impairment or significant ischemic burden, a conservative approach was followed. We highlight the role of multimodality imaging to depict CPAF anatomy and their relationship with relevant cardiac structures, and the role of stress testing in guiding therapy.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Ethical disclosures</span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Protection of human and animal subjects</span><p id="par0020" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this investigation.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Confidentiality of data</span><p id="par0025" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data and that all the patients included in the study received sufficient information and gave their written informed consent to participate in the study.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Right to privacy and informed consent</span><p id="par0030" class="elsevierStylePara elsevierViewall">The authors have obtained the written informed consent of the patients or subjects mentioned in the article. The corresponding author is in possession of this document.</p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflicts of interest</span><p id="par0035" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:3 [ "identificador" => "sec0005" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0010" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0015" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0020" "titulo" => "Right to privacy and informed consent" ] ] ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflicts of interest" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2012-06-11" "fechaAceptado" => "2012-06-18" "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:2 [ 0 => array:4 [ "apendice" => "<p id="par0040" class="elsevierStylePara elsevierViewall">Supplementary material associated with this article can be found in the online version available at <span class="elsevierStyleInterRef" href="doi:10.1016/j.repc.2012.06.013">doi:10.1016/j.repc.2012.06.013</span></p>" "etiqueta" => "Appendix A" "titulo" => "Supplementary material" "identificador" => "sec0030" ] 1 => array:4 [ "apendice" => "<p id="par0045" class="elsevierStylePara elsevierViewall"><elsevierMultimedia ident="upi0005"></elsevierMultimedia><elsevierMultimedia ident="upi0010"></elsevierMultimedia><elsevierMultimedia ident="upi0015"></elsevierMultimedia><elsevierMultimedia ident="upi0020"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia></p>" "etiqueta" => "Appendix A" "titulo" => "Supplementary data" "identificador" => "sec0035" ] ] ] ] "multimedia" => array:12 [ 0 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 844 "Ancho" => 1900 "Tamanyo" => 435110 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Admission 12-lead electrocardiogram showing no relevant ST-segment changes.</p>" ] ] 1 => array:7 [ "identificador" => "fig0030" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 468 "Ancho" => 1400 "Tamanyo" => 96909 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">(A): coronary angiography depicting no obstructive epicardial disease in the left dominant coronary circulation. (B and C): the right coronary artery was a small caliber vessel, with significant tortuosity in its proximal segment, but with no obstructive disease. An abnormal vessel was noted (arrows) arising from its proximal course and heading left, toward a posterior-superiorly located structure. LAD: left anterior descending artery; LCx: left circumflex artery; RCA: right coronary artery.</p>" ] ] 2 => array:7 [ "identificador" => "fig0035" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 594 "Ancho" => 1400 "Tamanyo" => 95833 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Multislice computed tomography. (A): 2D multiplanar reformatted image revealing a fistulous connection (arrows) between the proximal right coronary artery (RCA) and the left atrium (LA). (B): 3D volume-rendered image showing the fistula (arrows) arising from the proximal right coronary artery with a retro-aortic course. RA: right atrium; RVOT: right ventricular outflow tract.</p>" ] ] 3 => array:7 [ "identificador" => "fig0040" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1331 "Ancho" => 1800 "Tamanyo" => 333033 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Exercise single-photon emission computed tomography using standard Bruce protocol (8:43 minutes achieving 85% of the age-predicted maximum heart rate, 10.1 metabolic equivalents) showing no residual ischemia.</p>" ] ] 4 => array:5 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:2 [ "fichero" => "mmc1.doc" "ficheroTamanyo" => 23040 ] ] 5 => array:6 [ "identificador" => "upi0010" "etiqueta" => "Video 1" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc2.avi" "ficheroTamanyo" => 881824 "Video" => array:2 [ "flv" => array:5 [ "fichero" => "mmc2.flv" "poster" => "mmc2.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] "mp4" => array:2 [ "fichero" => "mmc2.m4v" "poster" => "mmc2.jpg" ] ] ] ] 6 => array:6 [ "identificador" => "upi0015" "etiqueta" => "Video 2" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc3.avi" "ficheroTamanyo" => 530368 "Video" => array:2 [ "flv" => array:5 [ "fichero" => "mmc3.flv" "poster" => "mmc3.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] "mp4" => array:2 [ "fichero" => "mmc3.m4v" "poster" => "mmc3.jpg" ] ] ] ] 7 => array:6 [ "identificador" => "upi0020" "etiqueta" => "Video 3" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc4.avi" "ficheroTamanyo" => 698604 "Video" => array:2 [ "flv" => array:5 [ "fichero" => "mmc4.flv" "poster" => "mmc4.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] "mp4" => array:2 [ "fichero" => "mmc4.m4v" "poster" => "mmc4.jpg" ] ] ] ] 8 => array:5 [ "identificador" => "fig0005" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "mmc5.jpeg" "Alto" => 836 "Ancho" => 750 "Tamanyo" => 64233 ] ] ] 9 => array:5 [ "identificador" => "fig0010" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "mmc6.jpeg" "Alto" => 626 "Ancho" => 1500 "Tamanyo" => 88644 ] ] ] 10 => array:5 [ "identificador" => "fig0015" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "mmc7.jpeg" "Alto" => 605 "Ancho" => 1000 "Tamanyo" => 108231 ] ] ] 11 => array:5 [ "identificador" => "fig0020" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "mmc8.jpeg" "Alto" => 578 "Ancho" => 953 "Tamanyo" => 71739 ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/08702551/0000003200000002/v1_201308021304/S0870255112003174/v1_201308021304/en/main.assets" "Apartado" => array:4 [ "identificador" => "357" "tipo" => "SECCION" "pt" => array:2 [ "titulo" => "Imagens em cardiologia" "idiomaDefecto" => true ] "idiomaDefecto" => "pt" ] "PDF" => "https://static.elsevier.es/multimedia/08702551/0000003200000002/v1_201308021304/S0870255112003174/v1_201308021304/en/main.pdf?idApp=UINPBA00004E&text.app=https://revportcardiol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255112003174?idApp=UINPBA00004E" ]
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| 2018 Junho | 62 | 6 | 68 |
| 2018 Maio | 58 | 5 | 63 |
| 2018 Abril | 74 | 3 | 77 |
| 2018 Maro | 96 | 11 | 107 |
| 2018 Fevereiro | 58 | 5 | 63 |
| 2018 Janeiro | 52 | 5 | 57 |
| 2017 Dezembro | 95 | 9 | 104 |
| 2017 Novembro | 59 | 14 | 73 |
| 2017 Outubro | 41 | 9 | 50 |
| 2017 Setembro | 48 | 10 | 58 |
| 2017 Agosto | 50 | 14 | 64 |
| 2017 Julho | 38 | 7 | 45 |
| 2017 Junho | 52 | 16 | 68 |
| 2017 Maio | 57 | 18 | 75 |
| 2017 Abril | 42 | 4 | 46 |
| 2017 Maro | 85 | 2 | 87 |
| 2017 Fevereiro | 148 | 10 | 158 |
| 2017 Janeiro | 29 | 4 | 33 |
| 2016 Dezembro | 40 | 7 | 47 |
| 2016 Novembro | 55 | 9 | 64 |
| 2016 Outubro | 42 | 6 | 48 |
| 2016 Setembro | 55 | 7 | 62 |
| 2016 Agosto | 20 | 4 | 24 |
| 2016 Julho | 5 | 2 | 7 |
| 2016 Junho | 13 | 6 | 19 |
| 2016 Maio | 3 | 7 | 10 |
| 2016 Abril | 33 | 2 | 35 |
| 2016 Maro | 46 | 15 | 61 |
| 2016 Fevereiro | 79 | 21 | 100 |
| 2016 Janeiro | 71 | 17 | 88 |
| 2015 Dezembro | 69 | 15 | 84 |
| 2015 Novembro | 71 | 14 | 85 |
| 2015 Outubro | 78 | 21 | 99 |
| 2015 Setembro | 75 | 12 | 87 |
| 2015 Agosto | 55 | 10 | 65 |
| 2015 Julho | 139 | 8 | 147 |
| 2015 Junho | 54 | 2 | 56 |
| 2015 Maio | 55 | 6 | 61 |
| 2015 Abril | 57 | 16 | 73 |
| 2015 Maro | 86 | 11 | 97 |
| 2015 Fevereiro | 117 | 15 | 132 |
| 2015 Janeiro | 97 | 4 | 101 |
| 2014 Dezembro | 106 | 7 | 113 |
| 2014 Novembro | 99 | 8 | 107 |
| 2014 Outubro | 96 | 5 | 101 |
| 2014 Setembro | 125 | 11 | 136 |
| 2014 Agosto | 94 | 9 | 103 |
| 2014 Julho | 102 | 7 | 109 |
| 2014 Junho | 94 | 3 | 97 |
| 2014 Maio | 109 | 13 | 122 |
| 2014 Abril | 102 | 9 | 111 |
| 2014 Maro | 117 | 14 | 131 |
| 2014 Fevereiro | 110 | 9 | 119 |
| 2014 Janeiro | 121 | 15 | 136 |
| 2013 Dezembro | 70 | 12 | 82 |
| 2013 Novembro | 77 | 16 | 93 |
| 2013 Outubro | 80 | 16 | 96 |
| 2013 Setembro | 69 | 16 | 85 |
| 2013 Agosto | 52 | 26 | 78 |
| 2013 Julho | 55 | 14 | 69 |
| 2013 Junho | 43 | 13 | 56 |
| 2013 Maio | 80 | 20 | 100 |
| 2013 Abril | 77 | 32 | 109 |
| 2013 Maro | 89 | 46 | 135 |
| 2013 Fevereiro | 33 | 17 | 50 |
Mostrar tudo
