Aug 28, 2017 - On clinical examination a continuous murmur could be heard ... echocardiogram observed a continuous flow of color in the high parasternal ...
International Journal of Current Medical and Pharmaceutical Research Available Online at http://www.journalcmpr.com ISSN: 2395-6429
DOI: http://dx.doi.org/10.24327/23956429.ijcmpr20170198
CASE REPORT RIGHT CORONARY ARTERY FISTULA TO PULMONARY TRUNK DIAGNOSED WITH CORONARY ANGIOGRAPHY: A CASE REPORT Redoy Ranjan1., Dipannita Adhikary2., Sabita Mandal3., Heemel Saha4., Sanjoy Kumar Saha5 and Asit Baran Adhikary6 1Department
of Cardiac Surgery, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh 2MPH Student, North South University, 3Dhaka, Bangladesh Department of Community medicine, Shaheed Suhrawardy Medical College, Dhaka 4Al Helal Specialized Hospital 5Department of Cardiac Anesthesia, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh 6Department of Cardiac Surgery, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh ARTICLE INFO
ABSTRACT
Article History: Received 15th May, 2017 Received in revised form 3rd June, 2017 Accepted 16th July, 2017 Published online 28th August, 2017
A 35 years old young lady was presented with long history exertional dyspnoea and recent history of shortness of breath on daily activities. On clinical examination a continuous murmur could be heard mostly at left second intercostal space along the left parasternal area. A transthoracic color Doppler echocardiogram observed a continuous flow of color in the high parasternal short axis view, draining from proximal part of right coronary artery towards main pulmonary artery. A selective right coronary angiography demonstrates a fistulous tract communicating the proximal part of the right coronary artery with the main pulmonary trunk. This report evaluates the surgical outcome of a complex fistula involving right coronary artery and main pulmonary artery with single feeding vessel originating from the proximal part of the right coronary artery.
Key words: Coronary-pulmonary artery fistula
Copyright © 2017 Redoy Ranjan et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
INTRODUCTION Fistula are the abnormal communication between two epithelial surface and coronary artery fistulas are very rare anomalies that can be either congenital or acquired, and may originate from any of the main coronary arteries and drains into low pressure cardiac chambers, coronary sinus and pulmonary artery.1,2 Most of the coronary-pulmonary artery fistulas are clinically, as well as hemodynamically insignificant and are usually found incidentally due to routine check-up for evaluation of other disease.2,9 Usually, conventional coronary angiography (CAG) has been used for the diagnosis of coronary artery disease. However, now-a-days frequent use of 64 slides multi detector CT scan(computed tomography) in chest and heart imaging, the incidental findings of coronary artery fistula have been increasing.3,4,5
on daily activities. Her past medical records represent normal ECG findings, and Creatinine kinase level. Chest radiography was unremarkable. However, stress test was mildly positive. On clinical examination, there was a continuous flow murmur mostly heard at left second intercostal space along the left parasternal area. A transthoracic Color Doppler echocardiogram was performed and observed a continuous
Case Report A 35 years old young lady was presented with long history exertional dyspnoea and recent history of shortness of breath
Figure 1 Transthoracic Color Doppler echocardiography (1a; 1b). Continuous flow of color draining from proximal part of right coronary artery towards main pulmonary artery.
International Journal Of Current Medical And Pharmaceutical Research, Vol. 3, Issue, 08, pp.2207-2209, August, 2017
flow of color in the high parasternal short axis view, draining from proximal part of right coronary artery towards main pulmonary artery (Figure-1). A selective right coronary angiography (CAG) demonstrates a fistulous tract communicating the proximal part (conus branch) of the right coronary artery with the main pulmonary artery (Green arrow and circle). This Green arrows represents drainage of blood from RCA (right coronary artery) into the pulmonary artery (Figure-2).
With all aseptic precaution, standard median sternotomy was done followed by thymectomy and pericardiotomy was performed. A complete CPB (cardiopulmonary bypass) was kept ready and per-operative color Doppler scan was revealed continuous flow murmur throughout the fistulous tract from RCA to PA. After confirming the fistula, off pump beating heart surgical reconstruction of fistulous tract was performed with non-absorbable suture (Polypropylene, 4/0) using multiple interrupted stitch and electro-cauterization of small channels arising from the fistula. Her Post-operative period was uneventful and patient got discharges from Hospital on 7th Postoperative day. On follow-up at 3 months postoperatively, patient was doing well and was free from any sort of dyspnoea or shortness of breath.
DISCUSSION
Figure 2 Coronary angiogram demonstrates fistulous tract originating from Conus branch of Proximal RCA and drainage into the main pulmonary artery (Green Arrow and circle marked).
Though anatomy of coronary-pulmonary artery fistula was complex, however fistula tract was well delineated after proper evaluation with CAG. The RCA (right coronary artery) arises from right coronary sinus, and the LCA (left coronary artery) arises from left coronary sinus which gives rise to Left anterior descending artery (LAD) and Left circumflex artery (LCX). This case was right coronary dominance and the fistula tract was arising from the proximal part of the RCA and have a courses horizontally to the anterior of the pulmonary trunk just above the pulmonary valve up to lateral margin of pulmonary artery. Finally, fistulous tract was ended by forming a 25 mm dilated malformation over the anterior aspect at the base of the pulmonary trunk before draining into the pulmonary artery (Figure-3).
Coronary-Atrial Fistula(CAF) was first described by Krause in 1865.1Though, CAF can be either congenital or acquired, but most of CAFs case are reported as a congenital case and acquired CAF are rarely discussed.1,2 However, the incidence of congenital CAF are approximately 0.2% to 0.4% and have a prevalence of 0.002% in the general population, but on Coronary angiography, CAFs are present in 0.05-0.25% of patients.3,5,6,8 There are no sex or race predilection for CAFs.10 Most common site for CAFs are either right coronary artery or left anterior descending artery and commonly drain in lowpressures chambers including right side of the heart, coronary sinus, superior cava vein and pulmonary artery.1,2,7-9 However, CAFs may originate from the left coronary artery too and incidence rate about 35% of cases and 17% cases drainage into the pulmonary artery.2,10,11,12 Coronary fistulae may give rise to serious cardiac complications, like myocardial ischemia, pulmonary hypertension, congestive cardiac failure, rupture of aneurysmal fistulous tract, embolization and Stroke leading to life threatening complications.11,13 Coronary CTAngiogram is a modernnon-invasive imaging modality that has been used for coronary artery imaging since 2000.12,13,14 With the use of MDCT (multi-detector computed tomography), problems with image quality have been overcome.11,13,14 With 128-slice MDCT is capable of producing high quality images with the ECG-gated image reconstruction algorithms allowing phase correlated image data sets that demonstrates appropriate coronary artery image.13,14,15 Coronary CT Angiogram clearly delineates the cardiac chambers, coronary veins and the coronary arteries. So that CT angiogram has been used as the choice of investigation in demonstrating coronary artery anomalies and as well as suspected coronary artery fistulae.15Reconstructed images reveal the fistulous tract with communications, anomalous vessels, as well as dilated and tortuous coronary arteries and also aneurysmal sac. The part of the CAF draining into the pulmonary artery could not be evaluated reliably by either CT or catheter angiography due to low pressure circulation, which caused reduced blood flow and marked attenuation of the fistula caliber.14,15
CONCLUSION Figure 3 Per-operative figure demonstrating the course of CPF (coronary-pulmonary fistula) tract. (3a) Origin, course and drainage (black arrow marked) of fistula tract from RCA to main PA. (3b) Malformation at the anterior aspect of the base of Pulmonary artery (Blue marked area).
Right coronary artery is the commonest site for congenital coronary fistula and usually drain to right side of the heart that is low pressure zone like right sided chambers, coronary sinus, superior vena cava and also pulmonary artery. Surgical reconstruction of fistulous tract carries excellent result.
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International Journal Of Current Medical And Pharmaceutical Research, Vol. 3, Issue, 08, pp.2207-2209, August, 2017
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