Coronary arterial fistulas are rare communications between vessels or chambers of the heart. Although cardiac symptoms associated with fistulas are well described, fistulas are seldom considered in the differential diagnosis of acute myocardial ischemia. We describe the case of a 64-year-old man who presented with left shoulder pain, signs of heart failure, and a new left bundle branch block (LBBB). Cardiac catheterization revealed a small left anterior descending (LAD)-to-pulmonary artery (PA) fistula. Diuresis led to subjective improvement of the patient's symptoms and within several days the LBBB resolved. We hypothesize that the coronary fistula in this patient contributed to transient ischemia of the LAD territory through a coronary steal mechanism. We elected to observe rather than repair the fistula, as his symptoms and ECG changes resolved with treatment of his heart failure

Childers, Ryan E.

Chow, Grant V.

Hirsch, Glenn A.

Juraschek, Stephen P.

Kovell, Lara C.

English

PubMed

Coronary arterial fistulas are rare communications between vessels or chambers of the heart. Although cardiac symptoms associated with fistulas are well described, fistulas are seldom considered in the differential diagnosis of acute myocardial ischemia. We describe the case of a 64-year-old man who presented with left shoulder pain, signs of heart failure, and a new left bundle branch block (LBBB). Cardiac catheterization revealed a small left anterior descending (LAD)-to-pulmonary artery (PA) fistula. Diuresis led to subjective improvement of the patient's symptoms and within several days the LBBB resolved. We hypothesize that the coronary fistula in this patient contributed to transient ischemia of the LAD territory through a coronary steal mechanism. We elected to observe rather than repair the fistula, as his symptoms and ECG changes resolved with treatment of his heart failure.</jats:p

Stephen P. Juraschek

Lara C. Kovell

Ryan E. Childers

Grant V. Chow

Glenn A. Hirsch

Crossref

SAGE-Hindawi Access to ResearchCardiology Research and PracticeVolume 2011, Article ID 786287, 3 pagesdoi:10.4061/2011/786287Case ReportHeart Failure with Transient Left Bundle Branch Block inthe Setting of Left Coronary FistulaStephen P. Juraschek, Lara C. Kovell, Ryan E. Childers, Grant V. Chow, and Glenn A. HirschDepartment of Medicine, Johns Hopkins Bayview Medical Center, Johns Hopkins University School of Medicine,4940 Eastern Avenue, Baltimore, MD 21224, USACorrespondence should be addressed to Stephen P. Juraschek, spj@jhmi.eduReceived 25 November 2010; Accepted 11 January 2011Academic Editor: Hendrik T. TevaearaiCopyright © 2011 Stephen P. Juraschek et al. This is an open access article distributed under the Creative Commons AttributionLicense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properlycited.Coronary arterial fistulas are rare communications between vessels or chambers of the heart. Although cardiac symptomsassociated with fistulas are well described, fistulas are seldom considered in the diﬀerential diagnosis of acute myocardial ischemia.We describe the case of a 64-year-old man who presented with left shoulder pain, signs of heart failure, and a new left bundlebranch block (LBBB). Cardiac catheterization revealed a small left anterior descending (LAD)-to-pulmonary artery (PA) fistula.Diuresis led to subjective improvement of the patient’s symptoms and within several days the LBBB resolved. We hypothesize thatthe coronary fistula in this patient contributed to transient ischemia of the LAD territory through a coronary steal mechanism. Weelected to observe rather than repair the fistula, as his symptoms and ECG changes resolved with treatment of his heart failure.1. IntroductionCoronary arterial fistulas are rare cardiac anomalies that cre-ate new pathways of blood flow between coronary vessels andthoracic vasculature or chambers of the heart [1]. Althoughgenerally asymptomatic, patients can develop complicationsof thrombosis, congestive heart failure, rupture, endo-carditis, and arrhythmias [2]. Here, we describe a patientwith acute decompensated heart failure and transient leftbundle branch block (LBBB), found to have an underlyingleft anterior descending (LAD)-to-pulmonary artery (PA)fistula. This case illustrates the potential of coronary fistulasto induce a clinical presentation of cardiac ischemia via acoronary steal mechanism.2. Case ReportA 64-year-old man with a history of congestive heartfailure and stage IV chronic kidney disease secondary touncontrolled hypertension and diabetes mellitus presentedwith three days of orthopnea and one night of intermittentleft shoulder pain radiating to the back.Physical examination revealed a heart rate of 99 beatsper minute and blood pressure of 149/71 mm Hg with anoxygen saturation of 94% on 4 liters of oxygen. Bilateralrales were present in the lower and middle lung fields.Cardiac auscultation revealed distant heart sounds and aregular rate and rhythm without murmur. Jugular venouspressure was elevated to 10 cm H2O. Lower extremity pittingedema (2+) was present. Laboratory analyses were significantfor a hematocrit of 24% and creatinine of 3.8 mg/dL. Car-diac enzymes were normal. Twelve-lead electrocardiography(ECG) revealed sinus rhythm at 94 beats per minute and anew LBBB.An acute myocardial infarction was suspected and thepatient was taken for emergent cardiac catheterization, whichshowed stenosis of up to 40% of the mid-LAD coronaryartery and mild disease in other vessels. In addition, afistula was identified connecting the LAD to the distalmain PA (Figures 1(a) and 1(b)). The direction of bloodflow was from the coronary vessel into the pulmonarycirculation. No acute intervention was performed at thetime of cardiac catheterization. Transthoracic echocardio-graphy demonstrated moderate global systolic dysfunction2 Cardiology Research and PracticeLAD(a)LADPA(b)Figure 1: Right anterior oblique cranial views during coronary angiography revealed a fistula (arrow, a) arising from the left anteriordescending (LAD) artery, which was then found to empty into the pulmonary artery (PA) via a small branch (arrow, b).with a left ventricular ejection fraction of 40% as wellas a moderate-sized pericardial eﬀusion without echocar-diographic evidence of increased intrapericardial pressure.The patient was diuresed with intravenous furosemide withgradual symptomatic and objective improvement.A regadenoson nuclear perfusion stress imaging studyperformed after 4 days of diuresis and a blood transfusionwas negative for inducible ischemia. Furthermore, an ECGon the day of the stress imaging study showed resolutionof the LBBB, and one week later the patient’s ECG showedrecovery to near normal left ventricular ejection fraction anddecrease in size of the pericardial eﬀusion.We hypothesized that the small LAD-PA fistula wasnot the sole cause of heart failure symptoms but was acontributor to the patient’s clinical presentation and ECGfindings. The small fistula in this case “steals” from the LAD-supplied myocardium, including the left bundle. By itself,the fistula was not suﬃcient to manifest clinically. However,in the setting of increased oxygen demand and decreasedoxygen supply during the heart failure exacerbation, thiscoronary steal likely decreased the total oxygen supply in theLAD territory enough to cause additional transient ischemiaand LBBB.The patient was discharged after 7 days. Since hewas previously asymptomatic without objective evidence ofischemia in the absence of myocardial oxygen supply anddemand mismatch, we elected to continue close observationrather than closure of the fistula.3. DiscussionCoronary arterial fistulas are rare communications betweencoronary vasculature and thoracic vessels or cardiac cham-bers [1]. The most frequent sites of drainage include theventricles, pulmonary arteries, the coronary sinus, the supe-rior vena cava, or the pulmonary veins [1]. Of the diﬀerenttypes of fistulas, 42% originate from the left coronary treeand 17% drain into the pulmonary artery [3]. Fistulas aregenerally congenital in origin, but they can also arise fromcardiac trauma, chest irradiation, cardiac surgery, coronaryangioplasty, and endomyocardial biopsy [1].While fistulas are usually asymptomatic, their natu-ral history can be variable. Adult patients who developsymptoms often do so in the 5th or 6th decade [1, 2].Common clinical presentations include dyspnea, congestiveheart failure, angina, aneurysm, or myocardial infarction[4]. Whether or not a patient will develop symptomsis determined by the degree of fistula-induced volumeoverload, as well as the severity of left-to-right shuntingsecondary to fistula size and location [1].Coronary angiography is the primary diagnostic tool fordefining fistula anatomy [2]. Transesophageal echocardio-gram may be useful in delineating the origin, course, anddrainage of a fistula [5]. Closure rarely occurs spontaneouslyin adults. Therefore, in the presence of large shunts or even inasymptomatic patients, surgical or transcatheter ligation maybe considered to prevent long-term sequelae such as steal,spontaneous rupture, heart failure, or myocardial ischemia[6, 7]. Transcatheter closure is first-line therapy in suitableanatomic cases due to lower cost, shorter recovery time,and reduced hospital stay. This avoids thoracotomy andcardiopulmonary bypass, which could accompany a surgicalapproach [8].This case has several limitations. Although coronarysteal may have contributed to ischemia of the left bundleas evidenced by subsequent ECG findings, we cannotexclude a rate-related bundle branch block. However, thisis less likely since an ECG tracing 5 months earlier, at thesame heart rate, revealed a normal QRS duration as didCardiology Research and Practice 3subsequent ECG tracings at similar heart rates. A right heartcatheterization was not performed to assess filling pressuresor to calculate a shunt fraction. Even without direct measuresof these pressures, it was still evident that the patient wasin congestive heart failure by history and physical examfindings. He improved significantly with diuresis, suggestingelevated filling pressures also contributed to the supply-demand mismatch. The left ventricular systolic function mayhave also appeared decreased at presentation because of theseptal motion abnormality from the LBBB.4. ConclusionsOur patient, who presented with orthopnea, shoulder pain,and a new LBBB, illustrates that even a small coronary fistulamay “steal” enough blood flow to mimic the symptoms of anacute myocardial infarction in the setting of a transient oxy-gen supply-demand mismatch. A coronary fistula, therefore,may not be the sole culprit lesion or an innocent bystander,but an accomplice in causing signs and symptoms of acuteheart failure.Disclosures and Financial SupportThe authors have no disclosures or financial conflicts ofinterest relevant to this paper to report. All authors contrib-uted to the writing, editing, and content of this manuscript.References[1] S. Balanescu, G. Sangiorgi, S. Castelvecchio, M. Medda, andL. Inglese, “Coronary artery fistulas: clinical consequences andmethods of closure. A literature review,” Italian Heart Journal,vol. 2, no. 9, pp. 669–676, 2001.[2] S. A. Qureshi, “Coronary arterial fistulas,” Orphanet Journal ofRare Diseases, vol. 1, no. 51, pp. 1–6, 2006.[3] D. C. Levin, K. E. Fellows, and H. L. Abrams, “Hemodynam-ically significant primary anomalies of the coronary arteries.Angiographic aspects,” Circulation, vol. 58, no. 1, pp. 25–34,1978.[4] R. M. Gowda, B. C. Vasavada, and I. A. Khan, “Coronary arteryfistulas: clinical and therapeutic considerations,” InternationalJournal of Cardiology, vol. 107, no. 1, pp. 7–10, 2006.[5] L. Olivotti, S. Moshiri, G. Santoro, A. Nicolino, and F. Chiarella,“Percutaneous closure of a giant coronary arteriovenous fistulausing free embolization coils in an adult patient,” Journal ofCardiovascular Medicine, vol. 9, no. 7, pp. 733–736, 2008.[6] T. Tirilomis, I. Aleksic, T. Busch, D. Zenker, W. Ruschewski,and H. Dalichau, “Congenital coronary artery fistulas inadults: surgical treatment and outcome,” International Journalof Cardiology, vol. 98, no. 1, pp. 57–59, 2005.[7] Y. Ata, T. Turk, M. Bicer, M. Yalcin, F. Ata, and S. Yavuz,“Coronary arteriovenous fistulas in the adults: natural historyand management strategies,” Journal of Cardiothoracic Surgery,vol. 4, no. 1, p. 62, 2009.[8] X. Y. Zhu, D. Z. Zhang, X. M. Han et al., “Transcatheter closureof congenital coronary artery fistulae: immediate and long-termfollow-up results,” Clinical Cardiology, vol. 32, no. 9, pp. 506–512, 2009.Submit your manuscripts athttp://www.hindawi.comStem CellsInternationalHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014MEDIATORSINFLAMMATIONofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Behavioural NeurologyEndocrinologyInternational Journal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Disease MarkersHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014BioMed Research InternationalOncologyJournal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Oxidative Medicine and Cellular LongevityHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014PPAR ResearchThe Scientific World JournalHindawi Publishing Corporation http://www.hindawi.com Volume 2014Immunology ResearchHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Journal ofObesityJournal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014 Computational and  Mathematical Methods in MedicineOphthalmologyJournal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Diabetes ResearchJournal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Research and TreatmentAIDSHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Gastroenterology Research and PracticeHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Parkinson’s DiseaseEvidence-Based Complementary and Alternative MedicineVolume 2014Hindawi Publishing Corporationhttp://www.hindawi.com

Cardiology Research and Practice

Heart Failure with Transient Left Bundle Branch Block in the Setting of Left Coronary Fistula

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Heart Failure with Transient Left Bundle Branch Block in the Setting of Left Coronary Fistula

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