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

2.  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

3.  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

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

5.  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.

6.  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

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

8. 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.

9. Echo: Short axis view

10. Echo: 5 chamber view

11. LAO, Cranial view (D= 3.3)

12. RAO view

13. Caudal view

14. Passing the exchange wire

15. Insertion of 9*6 coil

16. Insertion of coil

17. Released coil

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

19. 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

20. LAO, Cranial view (D=4.2mm)

21. Caudal view

22. Making the loop

23. Injection in fistula

24. Insertion of 11*6 coil

25. Released coil

26. Follow up  No residual flow after 6 mo

27. 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

28. LAO, cranial view

29. Injections into fistula (D=3.5mm)

30. Insertion of 9*6 coil

31. Released coil

32. Residual leakage

33. Release of second 5*4 coil

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

36. 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

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

41. Aortogram in LAO view

45. 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

46. Thank you for your attention