Anjo, D.

Antunes, M.

Cyrne-Carvalho, H.

Palma, P.

Silva-Vieira, M.

Torres, S.

Repositório Científico da Unidade Local de Saúde de Santo António

Document downRev Port Cardiol. 2013;32(2):165--167Revista Portuguesa deCardiologiaPortuguese Journal of Cardiologywww.revportcardiol.orgIMAGES IN CARDIOLOGYCoronary  artery  ﬁstula  presenting  as  unstable  anginaFístula  de  artéria  coronária  apresentando-se  como  angina  instávelMiguel Silva Vieira ∗, Nuno Antunes, Diana Anjo, Paulo Palma, Henrique Carvalho,Severo  TorresCardiology  Department,  Hospital  Santo  António,  Centro  Hospitalar  do  Porto,  Porto,  PortugalReceived  11  June  2012;  accepted  18  June  2012loaded from http://www.elsevier.pt, day 04/11/2014. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited.Available  online  31  December  2012baesfpnocfctaA  74-year-old  man,  with  a  history  of  heavy  smoking,  pre-sented  with  unstable  angina  (Figure  1).  Dobutamine  stressechocardiography  showed  ischemia  in  the  right  coronaryartery  territory.  Coronary  angiography  revealed  no  obstruc-tive  epicardial  disease  in  the  left  dominant  circulation(Figure  2A);  the  right  coronary  artery  (RCA)  was  a  smallcaliber  and  tortuous  vessel,  with  only  minor  atheroma.However,  an  abnormal  vessel  arising  from  the  proximalRCA  was  noted  (Figure  2B  and  C),  conﬁrmed  as  a  ﬁstu-lous  connection  to  the  left  atrium  by  multislice  computedtomography,  which  also  excluded  other  vascular  anoma-lies  (Figure  3).  This  was  deemed  to  be  causing  a  coronarysteal  phenomenon.  Exercise  myocardial  perfusion  imag-ing  under  anti-ischemic  therapy  excluded  residual  ischemiaand  the  patient  was  successfully  conservatively  managed(Figure  4).Coronary-pulmonary  artery  ﬁstulas  (CPAF)  are  rare,  oftenincidental  ﬁndings  of  coronary  angiography,  thought  to∗ Corresponding author.E-mail address: zemiguelvieira@gmail.com (M.S. Vieira).tast0870-2551/$  –  see  front  matter  ©  2012  Sociedade  Portuguesa  de  Cardiologhttp://dx.doi.org/10.1016/j.repc.2012.06.013e  remnants  of  a  vascular  connection  from  the  medi-stinal  mesoderm.  Coronary  steal  has  been  reportedven  in  small  ﬁstulas,  due  to  runoff  to  a  low-pressureystem,  with  reduction  of  intracoronary  diastolic  per-usion  pressure.  Treatment  should  be  based  on  theresence  of  symptoms  and  anatomy  (number  and  size,ature  of  feeding  vessel,  draining  site,  quantiﬁcationf  myocardium  at  risk  of  ischemia  and  shunt),  withatheter  and  surgical  options  being  offered  if  technicallyeasible.Given  the  ﬁstula’s  small  size,  from  a  non-dominantoronary  artery,  and  in  the  absence  of  right  ven-ricular  impairment  or  signiﬁcant  ischemic  burden, conservative  approach  was  followed.  We  highlighthe  role  of  multimodality  imaging  to  depict  CPAFnatomy  and  their  relationship  with  relevant  cardiactructures,  and  the  role  of  stress  testing  in  guidingherapy.ia.  Published  by  Elsevier  España,  S.L.  All  rights  reserved.166  M.S.  Vieira  et  al.Figure  1  Admission  12-lead  electrocardiogram  showing  no  relevant  ST-segment  changes.Figure  2  (A):  coronary  angiography  depicting  no  obstructive  epicardial  disease  in  the  left  dominant  coronary  circulation.  (B  andC): the  right  coronary  artery  was  a  small  caliber  vessel,  with  signiﬁcant  tortuosity  in  its  proximal  segment,  but  with  no  obstructivedisease. An  abnormal  vessel  was  noted  (arrows)  arising  from  its  proximal  course  and  heading  left,  toward  a  posterior-superiorlylocated structure.  LAD:  left  anterior  descending  artery;  LCx:  left  circumﬂex  artery;  RCA:  right  coronary  artery.Figure  3  Multislice  computed  tomography.  (A):  2D  multiplanar  reformatted  image  revealing  a  ﬁstulous  connection  (arrows)between the  proximal  right  coronary  artery  (RCA)  and  the  left  atrium  (LA).  (B):  3D  volume-rendered  image  showing  the  ﬁstula(arrows) arising  from  the  proximal  right  coronary  artery  with  a  retro-aortic  course.  RA:  right  atrium;  RVOT:  right  ventricular  outﬂowtDocument downloaded from http://www.elsevier.pt, day 04/11/2014. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited.ract.Coronary  artery  ﬁstula  presenting  as  unstable  angina  167phy  ents)siCTASupplementary  material  associated  with  this  arti-Document downloaded from http://www.elsevier.pt, day 04/11/2014. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited.Figure  4  Exercise  single-photon  emission  computed  tomograthe age-predicted  maximum  heart  rate,  10.1  metabolic  equivalEthical disclosuresProtection  of  human  and  animal  subjects.  The  authorsdeclare  that  no  experiments  were  performed  on  humans  oranimals  for  this  investigation.Conﬁdentiality  of  data.  The  authors  declare  that  they  havefollowed  the  protocols  of  their  work  center  on  the  publica-tion  of  patient  data  and  that  all  the  patients  included  in  thestudy  received  sufﬁcient  information  and  gave  their  writteninformed  consent  to  participate  in  the  study.Right  to  privacy  and  informed  consent.  The  authors  haveobtained  the  written  informed  consent  of  the  patients  orcdusing  standard  Bruce  protocol  (8:43  minutes  achieving  85%  of showing  no  residual  ischemia.ubjects  mentioned  in  the  article.  The  corresponding  authors  in  possession  of  this  document.onﬂicts of interesthe  authors  have  no  conﬂicts  of  interest  to  declare.ppendix A. Supplementary materialle  can  be  found  in  the  online  version  available  atoi:10.1016/j.repc.2012.06.013

Fístula de artéria coronária apresentando-se como angina instável

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Fístula de artéria coronária apresentando-se como angina instável

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