H. Amoozgar, MD Professor of pediatric cardiology Shiraz University of Medical Sciences, Shiraz, Iran TRANSCATHETER CLOSURE OF LARGE CORONARY-CAMERAL FISTULAE

 Coronary artery fistulas, although rare, represent the most common congenital coronary artery malformations.  They have been described in 0.25% to 0.4% of patients with congenital heart disease

 They may connect a coronary artery and one of the cardiac chambers, the coronary sinus, the superior vena cava, or the pulmonary artery.  More than 50% of the fistulas arise from the right, 30% arising from the left and 5% arising from both coronary arteries

Complications  fistulas may result:  congestive heart failure  bacterial endocarditis  coronary artery rupture  coronary ischemia  myocardial infarction induced by a coronary ‘‘steal’’ phenomenon

 Interventional occlusion of coronary artery fistulas is a well-accepted alternative to surgical therapy.  occlusion of high-flow lesions in children, necessitating implantation of large occluding devices, may be limited by the requirement of large delivery catheters.

 Successful occlusion of large fistulas has been reported with various types of detachable occluding devices including :  Gianturco coils or detachable coils  The Amplatzer vascular plug  the Amplatzer duct occluder,  the Rashkind double-umbrella device  the Amplatzer ventricular septal defect (VSD) occluder

 Following cases are our experience with closure of these fistula by PFM- coil

Case 1  4 mo old boy with excessive perspiration and tachycardia from birth.  Continues murmur 3/6 in left lower sternal border.  Cardio/Thorax ratio 65%  Normal heart function in echocardiography and dilated left coronary artery with abnormal flow in septum.

Echo: Short axis view

Echo: 5 chamber view

LAO, Cranial view (D= 3.3)

RAO view

Caudal view

Passing the exchange wire

Insertion of 9*6 coil

Insertion of coil

Released coil

Follow up  No ischemic change in ECG  No residual after 2 weeks

Case 2  2 years old girl with excessive perspiration and tachycardia from birth.  Continues murmur 3/6 in left lower sternal border.  Cardio/Thorax ratio 55%  Normal heart function in echocardiography and Dilated LV

LAO, Cranial view (D=4.2mm)

Caudal view

Making the loop

Injection in fistula

Insertion of 11*6 coil

Released coil

Follow up  No residual flow after 6 mo

Case 3  3 years old boy with excessive perspiration and tachycardia from birth.  Continues murmur 3/6 in left lower sternal border.  Cardio/Thorax ratio45%  Normal heart function in echocardiography

LAO, cranial view

Injections into fistula (D=3.5mm)

Insertion of 9*6 coil

Released coil

Residual leakage

Release of second 5*4 coil

Follow up  Minimal residual flow after 6mo  Nl heart function

Case 4  28 days neonate with respiratory distress.  Continues murmur in RUSB and RV tap and load P2 and hyperdynamic precordium  Echocardiography showed dilated RA and RV sever pulmonary hypertension possibility of anomalous pulmonary veinus return

Case 5  Patient with tachycardia  Referred to cardiologist and mild MR was detected. 

Aortogram in LAO view

Conclusion  PFM coil seems a suitable device for closure congenial cameral fistulas in children due to :  low thrombogenecity  small Sheet 4 or 5 F  Flexible sheet  Retrievability

Thank you for your attention