Author + information
- Received November 6, 2018
- Revision received November 28, 2018
- Accepted December 4, 2018
- Published online May 6, 2019.
- Carrie E. Herbert, MD∗ ( and )
- Gary E. Stapleton, MD
- Johns Hopkins All Children’s Heart Institute, Johns Hopkins All Children’s Hospital, Saint Petersburg, Florida
- ↵∗Address for correspondence:
Dr. Carrie E. Herbert, Johns Hopkins All Children's Hospital, Johns Hopkins All Children's Heart Institute, 601 5th Street South, Suite 206, St. Petersburg, Florida 33701.
Coronary artery fistula (CAF) is a rare complication of right ventricular (RV) biopsy, particularly in the adult population (1). We describe a child who developed CAF that required percutaneous closure.
Our patient underwent heart transplantation at age 18 months. Five months post-transplant, echocardiogram showed a CAF to the RV with mild dilation of the left main coronary artery (LMCA). Catheterization performed 9 months later showed no significant left-to-right shunt, mild dilation of the left coronary artery (LCA) system, with a CAF from the left anterior descending coronary artery (LAD) to the RV (Figure 1A). Four years later, the CAF had involuted (Figure 1B).
When the patient was 12 years old and weighed 33 kg, echocardiogram showed dilation of the LCA with a large CAF to the RV. Catheterization demonstrated a Qp:Qs of 1.42:1. Coronary angiography showed diffuse dilation of the LMCA and LAD. The proximal LMCA measured 6.5 mm. The LAD measured 8.5 mm proximally with a widest diameter of 10.7 mm (Figure 2A, Online Videos 1 and 2). There was no residual flow through the involuted fistula (Figure 2B). The CAF had 3 separate channels coalescing into 1 large fistula off the LAD (Figure 2C, Online Video 3). Retrograde access was obtained into the CAF, and an arteriovenous rail was made. A 12-mm Amplatzer Vascular Plug II (Abbott, Abbott Park, Illinois) was advanced through a 6-F long venous sheath and deployed in the fistula with the distal retention disc in the CAF, the middle lobe within the widest channel, and the proximal disc in the RV (Figure 3). Angiography in the LCA post-release showed no coronary artery obstruction from the device.
Repeat catheterization 8 months post-occlusion showed improved caliber of the LMCA (4.3 mm) and LAD (4.7 mm), with the most aneurysmal portion of the LAD now measuring 8.0 × 7.3 mm.
Both authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received November 6, 2018.
- Revision received November 28, 2018.
- Accepted December 4, 2018.
- 2019 American College of Cardiology Foundation