|Year : 2019 | Volume
| Issue : 1 | Page : 23-25
Dual coronary-pulmonary fistula firstly found at routine doppler echocardiogram
Grazia Casavecchia1, Stefano Zicchino1, Matteo Gravina1, Alessandro Martone2, Andrea Cuculo1, Luca Macarini1, Matteo Di Biase3, Natale Daniele Brunetti1
1 Cardiology Department, University of Foggia, Foggia, Italy
2 Cardiology Department, Ospedali Riuniti, Bari, Italy
3 GVM Care and Research, Bari, Italy
|Date of Web Publication||20-Mar-2019|
Natale Daniele Brunetti
University of Foggia, Foggia
Source of Support: None, Conflict of Interest: None
Congenital coronary-pulmonary fistulas (CPFs) are defined as an abnormal direct communication between one or more coronary arteries, with a cardiac or thoracic structure bypassing the capillary network. We report the case of a 73-year-old male, with a history of hypertension, asymptomatic for angina and dyspnea, who was referred for routine clinical control. Echocardiogram unexpectedly showed the presence of diastolic flow from the pulmonary trunk in parasternal short-axis view. Pulsed-wave Doppler confirmed the presence of diastolic flow and displayed the typical coronary flow pattern. Coronary angiography hence showed the presence of dual CPFs originating from the second segment of the left anterior descending coronary and the right coronary arteries. Careful routine Doppler echocardiograph examination may raise the suspicion of CPF in case of otherwise unexplained symptoms and may represent a simple, easy, repeatable tool for the first suspected diagnosis and follow-up of CPFs.
Keywords: Coronary anomaly, coronary fistula, doppler echocardiogram
|How to cite this article:|
Casavecchia G, Zicchino S, Gravina M, Martone A, Cuculo A, Macarini L, Di Biase M, Brunetti ND. Dual coronary-pulmonary fistula firstly found at routine doppler echocardiogram. J Cardiovasc Echography 2019;29:23-5
|How to cite this URL:|
Casavecchia G, Zicchino S, Gravina M, Martone A, Cuculo A, Macarini L, Di Biase M, Brunetti ND. Dual coronary-pulmonary fistula firstly found at routine doppler echocardiogram. J Cardiovasc Echography [serial online] 2019 [cited 2020 Nov 24];29:23-5. Available from: https://www.jcecho.org/text.asp?2019/29/1/23/254592
| Introduction|| |
Congenital coronary-pulmonary fistulas (CPFs) are defined as an abnormal direct communication between one or more coronary arteries, with a cardiac or thoracic structure bypassing the capillary network. CPFs represent rare anomalies with an incidence variable in echocardiographic (0.06–0.2%),, necropsy (14%), and angiographic studies (0.1%–0.67%).,,,,, Despite the described secondary forms (following chest trauma, complications of left main trunk procedures, or CABG), congenital forms represent the majority. Dyspnea and chest pain may be a frequent complaint in adults with CPFs, while, in the pediatric age group, the majority of cases are silent. The most common coronary artery of origin for CPFs is the left main/left anterior descending, followed by the right coronary artery. CPF most commonly terminates in the main pulmonary artery. The majority of CPFs are single (unilateral) communications, but bilateral (dual) fistulas, and multilateral, triple, and quadruple fistulas have been previously described.
| Case Report|| |
We report the case of a 73-year-old male, with a history of hypertension, asymptomatic for angina and dyspnea, who was referred for routine clinical control. Physical examination was normal, and electrocardiogram showed a sinus rhythm with left bundle branch block. Echocardiographic examination revealed normal left and right ventricular dimension, but a moderate left ventricular systolic dysfunction (ejection fraction 40%). Unexpectedly, parasternal short-axis view showed the presence of diastolic flow from the pulmonary trunk upward [Figure 1]a. The ostia of the left and right coronary arteries were therefore carefully examined to assess their exact origin from the aorta or pulmonary artery. Pulsed-wave Doppler confirmed the presence of diastolic flow and displayed the typical coronary flow pattern [Figure 1]b. Therefore, a CPF was suspected. The patient was thus sent to cathlab for coronary angiography that showed the presence of dual CPFs originating from the second segment of the left anterior descending coronary [Figure 1]c and the right coronary arteries [Figure 1]d. Clinical and echocardiographic follow-up showed progressive reduction of systolic function, however, with a left ventricular ejection fraction >50% and effort dyspnea.
|Figure 1: (a) Diastolic flow from the pulmonary trunk directed upward. (b) Pulsed-wave Doppler confirming typical coronary flow pattern. (c) Coronary-pulmonary fistula from the mid segment of the left anterior descending coronary artery (arrow). (d) Coronary-pulmonary fistula from the right coronary artery (arrow)|
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| Discussion|| |
Although the occurrence of congenital CPFs is rare, such anomalies could be the cause of different clinical conditions such as chest pain, exertion dyspnea, palpitations, and angina. Echocardiogram is an important tool for the detection of CPFs; when compared with coronary angio or angio computed tomography (CT), it is much simpler, easier, less expensive, safer, repeatable, and accurate. Occasionally, echocardiography could be the first-line method for the diagnosis of suspected congenital coronary artery fistulas.
Echocardiography can show the presence of dilated coronary arteries and ventricular chambers and a variety of associated congenital and acquired heart defects. In a case series from Vitarelli et al., transthoracic echocardiography was suggestive for the presence of coronary artery fistulas in 33% of cases and transesophageal echocardiography confirmed the diagnosis in all patients. Of course, the diagnosis of CPF must be always confirmed by coronary angiography or coronary CT that may not only eventually confirm the presence of CPFs, but also more clearly define the whole fistula characteristics (origin, pathway, and outflow) and identify possible complications. Echocardiography, ideal for first-line assessment, should be included within a multimodality imaging approach, especially in the differential diagnosis of CPFs, a potential challenging task.
| Conclusions|| |
Careful routine Doppler echocardiograph examination may raise the suspicion of CPF in case of otherwise unexplained symptoms and may represent a simple, easy, repeatable tool for the first suspected diagnosis and follow-up of CPFs.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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