Coronary-cameral fistulas in adults: Acquired types (second of two parts)

Abstract

Acquired coronary artery fistulas (CCFs) are infrequently detected during conventional coronary angiography. To delineate the characteristics of congenital (first part) and acquired (second part) CCFs in adults, a PubMed search was conducted for papers dealing with congenital or acquired CCFs. None of the publications describing patients with coronary-vascular fistulas were included. Papers dealing with pediatric subjects were excluded. From the world literature, a total of 243 adult patients were selected who had congenital (n = 159/243, 65%) and acquired (n = 84/243, 35%) CCFs. Among the acquired types (n = 72, 85.7%) were traumatic (iatrogenic (n = 65/72, 90%), accidental (n = 7/72, 10%) and (n = 12, 14.3%) spontaneously developing in relation to severe coronary atherosclerosis or myocardial infarction. A high incidence of spontaneous resolution of iatrogenic CCFs resulting from endomyocardial biopsy or following post-septal myectomy was reported. Spontaneous CCFs associated with myocardial ischemia or infarction resolved completely in 8% of the subjects. Early surgical intervention was the treatment of choice in acquired traumatic accidental CCFs. The congenital types are addressed in a previous issue of this journal (first part). In this review (second of two parts, part II), we describe the acquired coronary-cameral fistulas.

Keywords: Acquired coronary-cameral fistulas, Accidental coronary-cameral fistulas, Iatrogenic coronary-cameral fistulas, Spontaneous coronary-cameral fistulas, Coronary angiography, Spontaneous resolution, Surgical treatment

Core tip: The literature addressing acquired coronary artery fistulas (CCFs) is reviewed. A detailed classification of acquired CCFs is attempted. Acquired coronary artery fistulas are subdivided into spontaneous and traumatic types. The traumatic fistulas encounter iatrogenic and accidental subtypes. The iatrogenic fistulas are secondary to non-surgical interventions (endomyocardial biopsy, permanent pacing and implantable cardioverter-defibrillator leads, radiofrequency cardio-ablation, baro-trauma and transseptal puncture) and cardiac surgical procedures (septal myectomy and other cardiac surgical procedures). Diagnosis of acquired CCFs is suspected by clinical history and recurrence of symptoms, occurrence of a new continuous machinery cardiac murmur and a palpable thrill. Watchful waiting and supportive medical management may be advocated in the majority of acquired CCFs. Acquired traumatic accidental CCFs are indications for emergent surgical procedures. Within this entity of CCFs, each subtype has its own specific characteristics such as age of the subjects, origin, termination of fistulas or mechanism of injury and its specific treatment modality.