When a coronary artery fistula is not simply a fistula: Using multimodality imaging to demonstrate an unusual embryologic remnant Arash Salavitabar,

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Date of download: 6/22/2016 Copyright © The American College of Cardiology. All rights reserved. From: Management of coronary artery fistulae: Patient.

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Presentation transcript:

When a coronary artery fistula is not simply a fistula: Using multimodality imaging to demonstrate an unusual embryologic remnant Arash Salavitabar, MD, Anjali Chelliah, MD, David Kalfa, MD, PhD, Matthew A. Crystal, MD The Journal of Thoracic and Cardiovascular Surgery Volume 156, Issue 1, Pages 358-362 (July 2018) DOI: 10.1016/j.jtcvs.2018.02.032 Copyright © 2018 The American Association for Thoracic Surgery Terms and Conditions

Figure 1 A, Coronary computed tomography angiogram showing a severely dilated left main and left anterior descending coronary artery (*) with no evidence of a right coronary artery ostium, intercoronary “Connection #1” coursing anteriorly, and the fistula coursing toward the right ventricular outflow tract in an oblique axial plane. B, Three-dimensional volume-rendered computed tomography angiogram. Ao, Aorta; RVOT, right ventricular outflow tract; LAD, left anterior descending coronary artery. The Journal of Thoracic and Cardiovascular Surgery 2018 156, 358-362DOI: (10.1016/j.jtcvs.2018.02.032) Copyright © 2018 The American Association for Thoracic Surgery Terms and Conditions

Figure 2 A, Three-dimensional (3D) virtual model from the anteroposterior (left) and lateral (right) views. B, 3D-printed model with left anterior descending coronary artery as labeled. C, 3D-printed model with coronary arteries and inter-coronary connections hollowed out. A wire is seen coursing from the ostium of the left main coronary artery, through the LAD, and into intercoronary “Connection #1.” Left Cx, Circumflex branch of left coronary artery; LAD, left anterior descending coronary artery. The Journal of Thoracic and Cardiovascular Surgery 2018 156, 358-362DOI: (10.1016/j.jtcvs.2018.02.032) Copyright © 2018 The American Association for Thoracic Surgery Terms and Conditions

Figure 3 Still-frame picture of a transcatheter angiogram performed retrograde in the left anterior descending coronary artery in the anterior-posterior view. RVOT, Right ventricular outflow tract; RCA, right coronary artery; LAD, left anterior descending coronary artery. The Journal of Thoracic and Cardiovascular Surgery 2018 156, 358-362DOI: (10.1016/j.jtcvs.2018.02.032) Copyright © 2018 The American Association for Thoracic Surgery Terms and Conditions

Figure 4 Intraoperative picture of the 3 intercoronary connections coalescing into a fistula that enters the RVOT (A) and the exit point of the fistula into the RVOT, observed via a pulmonary arteriotomy (B). RVOT, Right ventricular outflow tract. The Journal of Thoracic and Cardiovascular Surgery 2018 156, 358-362DOI: (10.1016/j.jtcvs.2018.02.032) Copyright © 2018 The American Association for Thoracic Surgery Terms and Conditions

Intercoronary connections forming a coronary–cameral fistula to the RV outflow tract. The Journal of Thoracic and Cardiovascular Surgery 2018 156, 358-362DOI: (10.1016/j.jtcvs.2018.02.032) Copyright © 2018 The American Association for Thoracic Surgery Terms and Conditions

Video 1 Echocardiogram showing a color-compare clip of at least 1 large vessel coursing anteriorly and rightward in an oblique apical view. Video available at: http://www.jtcvsonline.org/article/S0022-5223(18)30395-7/fulltext. The Journal of Thoracic and Cardiovascular Surgery 2018 156, 358-362DOI: (10.1016/j.jtcvs.2018.02.032) Copyright © 2018 The American Association for Thoracic Surgery Terms and Conditions

Video 2 Rotating virtual 3-dimensional reconstructed model. Video available at: http://www.jtcvsonline.org/article/S0022-5223(18)30395-7/fulltext. The Journal of Thoracic and Cardiovascular Surgery 2018 156, 358-362DOI: (10.1016/j.jtcvs.2018.02.032) Copyright © 2018 The American Association for Thoracic Surgery Terms and Conditions

Video 3 Transcatheter angiogram performed retrograde in the left anterior descending coronary artery (LAD) in anteroposterior (left) and lateral (right) views during balloon occlusion of the proximal LAD. Video available at: http://www.jtcvsonline.org/article/S0022-5223(18)30395-7/fulltext. The Journal of Thoracic and Cardiovascular Surgery 2018 156, 358-362DOI: (10.1016/j.jtcvs.2018.02.032) Copyright © 2018 The American Association for Thoracic Surgery Terms and Conditions

Video 4 Intraoperative video of the 3 intercoronary connections coalescing into a fistula and entering the right ventricular outflow tract. Video available at: http://www.jtcvsonline.org/article/S0022-5223(18)30395-7/fulltext. The Journal of Thoracic and Cardiovascular Surgery 2018 156, 358-362DOI: (10.1016/j.jtcvs.2018.02.032) Copyright © 2018 The American Association for Thoracic Surgery Terms and Conditions

Video 5 Intraoperative video of the exit point of the fistula into the right ventricular outflow tract, observed via a pulmonary arteriotomy during an injection of cardioplegia solution into the aortic root. Video available at: http://www.jtcvsonline.org/article/S0022-5223(18)30395-7/fulltext. The Journal of Thoracic and Cardiovascular Surgery 2018 156, 358-362DOI: (10.1016/j.jtcvs.2018.02.032) Copyright © 2018 The American Association for Thoracic Surgery Terms and Conditions