Download 180-719-1-SP - International Cardiovascular Forum Journal

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UNIVERSITA' DEGLI STUDI - BARI
DIPARTIMENTO DELL'EMERGENZA
E DEI TRAPIANTI DI ORGANI (D.E.T.O.)
DIRETTORE: Prof.Michele Battaglia
Segretario Amministrativo: Rag.Vito De Mola
Tel+Fax 080 5478627
e-mail: [email protected]
Prof Marco Matteo Ciccone
Responsabili
Anestesia e Rianimazione
Cardiochirurgia
Chirurgia d’urgenza
Chirurgia Generale e Trapianti di Fegato
Chirurgia Veterinaria
Gastroenterologia
Malattie dell’Apparato Cardiovascolare
Medicina Interna,Endocrinologia, Andrologia
e Malattie Metaboliche
Nefrologia, Dialisi e Trapianti
Patologia Chirurgica
Urologia e Andrologia
Urologia, Andrologia e Trapianti di Rene
F.Bruno
L.De Luca Tupputi
N.Palasciano
V.Memeo
A.Crovace
A.Francavilla
S.Favale
F.Giorgino
F.P.Schena
F.Prete
A.Pagliarulo
F.P.Selvaggi
Bari, October, 27th 2015
To:
Professor Michael Henein
Editor-in-chief
International Cardiovascular Forum Journal
Dear Editor,
Please find enclosed an original paper entitled “An unusual case of ST elevation myocardial infarction in a
teenager with a coronary artery fistula.””, which we would like to submit for publication in International
Cardiovascular Forum Journal.
This paper reports a rare case of coronary artery fistula determining ST-elevation myocardial infarction in a young
boy.
All of the authors declare that this manuscript has not been published previously, it is not under consideration for
publication elsewhere, its publication is approved by all authors, and, if accepted, that it will not be published
elsewhere.
We benefit of the offer to publish for free (code 9-201601).
Dr. Francesca Cortese critically reviewed the intellectual content of the manuscript, and finally approved the
version to be submitted for publication.
Dr. Michele Gesualdo analysed coronary computer tomography angiography images and finally approved
the version to be submitted for publication.
Dr. Tommaso Acquaviva reviewed the manuscript’s intellectual content, and finally approved the version to
be submitted for publication.
Dr. Domenico Zanna reviewed the manuscript’s intellectual content, and finally approved the version to be
submitted for publication.
Dr Emanuela De Cillis performed the angiographic assessment, and finally approved the version to be
submitted for publication.
Prof. Alessandro Bortone performed the angiographic assessmen, and finally approved the version to be
submitted for publication.
Prof Marco Matteo Ciccone critically reviewed the intellectual content of the manuscript, and finally approved
the version to be submitted for publication.
Dr. Francesca Cortese will deal with all pre-publication correspondence.
None of the authors have any financial or other relations that could lead to a conflict of interest.
We look forward to hearing from you in due course.
Yours sincerely,
Francesca Cortese
Michele Gesualdo
Tommaso Acquaviva
Domenico Zanna
Emanuela De Cillis
Alessandro Bortone
Marco Matteo Ciccone
Address for correspondence:
Dr. Francesca Cortese
Piazza G. Cesare 11 - 70124 Bari Italy;
Tel +39-080-5478791, Fax +39-080-5478796
e-mail: [email protected]
An unusual case of ST elevation myocardial infarction in a teenager with a coronary artery
fistula.
Francesca Cortese1*, Michele Gesualdo1, Tommaso Acquaviva2, Domenico Zanna1, Emanuela De
Cillis2, Alessandro Bortone2, Marco Matteo Ciccone1.
1.Department of Cardiology, University of Bari, Italy;
2.Department of Cardiac Surgery, University of Bari, Italy.
Corresponding author:
Dr. Francesca Cortese
Piazza G. Cesare 11 - 70124 Bari Italy;
Tel +39-080-5478791, Fax +39-080-5478796
e-mail: [email protected]
Conflicts of interest: none.
Key words: coronary artery fistula; ST-elevation myocardial infarction; percutaneous closure.
Coronary artery fistula (CAF) is an abnormal connection between a coronary artery and any of the 4
chambers of the heart or any of the great vessels (superior vena cava, pulmonary artery, pulmonary
veins, or coronary sinus). This abnormality is most often congenital [1] and, although representing
the most common coronary arterial malformation, is a rare cardiac anomaly. The incidence is of
0.002% of the general population and of 0.4% of all cardiac malformations [2].
Fistulas originating from the right coronary artery account for 50% to 60% of cases, while those
from the left anterior descending artery for 25% to 42% of cases, 18.3% from the circumflex artery,
1.9% from the diagonal branch, and 0.7% from the left main coronary artery or circumflex-marginal
branch [3, 4]. The most common are single fistulas, with a prevalence ranging from 74% to 90%,
multiple fistulas occur in 10.7% to 16%, while both coronary arteries are involved in only 5% [2].
The right heart is the most frequent site of drainage of fistulas [5]; in particular, the pulmonary
artery is the drainage site in 15% to 43% of cases, followed by the right ventricle in 14% to 40%,
the right atrium in 19% to 26%, the left ventricle in 2% to 19%, the coronary sinus in 7%, the
superior vena cava in 1% and finally the left atrium in 5% to 6% [3, 4]. Moreover literature data
show that bilateral fistulas, accounting for 5% of the total, terminate more often into the pulmonary
artery (56%) than unilateral fistulas (17%) [2].
Pathological manifestations depend on the resistance of the connection and the fistula drainage site.
The resistance is determined by the characteristics (size, tortuosity, and length) of the fistula. Flow
through fistulas that drain in the right chambers occurs during the whole cardiac cycle loading both
ventricles, while when the drain is in the left atrium and pulmonary vein, volume overload affects
only the left heart. CAFs are usually asymptomatic at a young age, unless they are of large
dimensions. Symptoms can occur with the increase of age: fatigue, dyspnea, palpitations and
ischemic chest pain are the most frequent clinical manifestations whereas heart failure, pulmonary
hypertension, subacute bacterial endocarditis, rupture or thrombosis the extreme complications [6].
We report a rare case of bilateral CAF draining into the left atrium determining myocardial
infarction in a 18 year old boy.
A young man of 18 years, with no cardiovascular risk factors and without family history of juvenile
sudden death and ischemic heart disease was hospitalized for chest pain radiating to the left arm.
Medical history showed right lobar pneumonia at the age of 3 years, and a diagnosis of
myopericarditis at 14 years. The patient is not taking medication.
At the first medical contact blood pressure was 130/80 mmHg, the general, cardiac and pulmonary
examinations where in the normal range. The ECG showed sinus rhythm at the frequency of 68
bpm with ST-segment elevation from V3 to V6 and in D1, D2 and aVL, negative T waves in D3
and aVF. Chest X-ray showed enlargement of the cardiac silhouette, while echocardiogram
hypokinesis of the apex and of mid anterior segment with moderate impairment of left ventricular
ejection function (EF: 45%). Blood tests showed an increase of troponin value (34.73 ng / ml) and
no sign of inflammation.
Coronary angiography highlighted the presence of a CAF connecting the right coronary artery and
the first tract of the anterior descending artery with the left atrium (figure 1). CT angiography
confirmed the angiographic findings
CAF was percutaneously closed by using the intracoronary injection of Glubran, an adhesive
compound [7]. The coronary angiography performed after 48 hours showed the complete
obliteration of CAF (figure 2). The postoperative course was not complicated by clinical and
instrumental evidence of new myocardial ischemia. The patient was discharged in clinically stable
condition on aspirin and beta blocker therapy. After about one month, the patient was completely
asymptomatic with normalization of electrocardiographic abnormalities and left ventricular function
To the best of our knowledge, this is the first case of CAF which manifested itself at an early age
with myocardial infarction. Myocardial infarction is a rare complication of CAF, accounting for
about 5% of overall manifestations [8]. The pathological mechanism involved is the coronary steal
phenomena, because the fistula, a low resistance system, in appropriate circumstances, can
determine shunting of blood from coronary vessel to the left atrium, leading to myocardial
ischemia. The closure with percutaneous approach shows to be an effective method, mini-invasive
and safe.
Acknowledgements:
The authors state that they adhere to the statement of ethical publishing of the International
Cardiovascular Forum Journal [9].
Figure 1.
The arrows show CAF connecting the first tract of the anterior descending artery (right side of the
image) and the right coronary artery (left side of image) to the left atrium.
Figure 2.
Coronary angiography performed after 48 hours from the closure showing the absence of CAF.
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journals. International Cardiovascular Forum Journal 2015;2:2 DOI: 10.17987/icfj.v2i1.4