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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

 
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 . . . [Full Text of this Article]