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(Circulation. 1997;96:3779.)
© 1997 American Heart Association, Inc.

Articles

Left Anterior Descending Coronary Artery–to–Right Ventricle Fistula

David DeNofrio, MD; Elliot S. Barnathan, MD; ; Evan Loh, MD

From the Cardiovascular Division, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pa.

Correspondence to Evan Loh, MD, Hospital of the University of Pennsylvania, 9 Founders Pavilion, 3400 Spruce St, Philadelphia, PA 19104-4283.

	Introduction

Top Introduction

 
Coronary artery fistula is a rare complication of endomyocardial biopsy, reported to occur in up to 8% of cardiac transplant recipients. The coronary angiogram shown in the Figure was obtained from a 67-year-old man 3 years after orthotopic heart transplantation, after a continuous systolic and diastolic murmur was noted on physical exam. Color-flow images from a transesophageal echocardiogram before cardiac catheterization suggested a coronary artery–to–right ventricle communication.

View larger version (87K): [in this window] [in a new window]   Figure 1. Coronary angiograms (right anterior oblique view with cranial angulation) were obtained 2 years (left) and 3 years (right) after orthotopic heart transplantation. Note dramatic increase in diameter of left anterior descending coronary artery before fistula (arrow), which empties into right ventricle. This demonstrates extensive capacity of a denervated coronary artery to undergo flow-induced vascular remodeling.

Hemodynamics at the time of cardiac catheterization were notable for an aortic pressure of 140 mm Hg systolic and 85 mm Hg diastolic, a left ventricular end-diastolic pressure of 9 mm Hg, a right ventricular pressure of 28 mm Hg systolic and 4 mm Hg diastolic, a pulmonary artery mean pressure of 17 mm Hg, and a pulmonary capillary wedge pressure of 8 mm Hg. The cardiac output, determined by the Fick method, was 5.3 L/min, with a cardiac index of 2.7 L · min^-1 · m^-2. The mixed venous O₂ saturation was 72.4%, with a pulmonary artery O₂ saturation of 70.1%. Blood sampled at the apex of the right ventricle had an O₂ saturation of 86.2%.

Coronary angiography (Figure, right) revealed marked left anterior descending coronary artery (LAD) dilatation in the proximal, middle, and distal portions, with a fistula (arrow) communicating between the distal LAD and the right ventricle. The diameter of the LAD is substantially greater than it was 1 year earlier (left), representing significant vascular remodeling secondary to increased blood flow through the artery.

	Footnotes

 
The editor of Images in Cardiovascular Medicine is Hugh A. McAllister, Jr, MD, Chief, Department of Pathology, St Luke's Episcopal Hospital and Texas Heart Institute, and Clinical Professor of Pathology, University of Texas Medical School and Baylor College of Medicine.

Circulation encourages readers to submit cardiovascular images to Dr Hugh A. McAllister, Jr, St Luke's Episcopal Hospital and Texas Heart Institute, 6720 Bertner Ave, MC1-267, Houston, TX 77030.

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