Percutaneous Closure of a Coronary Fistula John Lasala MD, PhD Director, Interventional Cardiology

Case 56 year-old WF CC: Left sided CP lasting 5-10min; not associated with exertion PMHx: DM2 Hyperlipidemia SHx: Positive for Tobacco use FHx: Positive for premature CAD Prior work-up: EBCT – 600 Agaston Units

Case - LHC (AP Caudal)

Case – LHC (LAO Caudal)

Case – LHC (AP Cranial)

Case – LHC (LAO view of the RCA)

Case – LHC (RAO view of RCA)

Case LHC RHC no significant CAD Complex coronary fistulas between the LAD and RCA with the pulmonary artery RHC Qp/Qs – 1.3 5% step up from the RV to the PA Elevated right sided pressures – PA 42/21 mmHg

Coronary Fistulas Rare PE – continuous murmur Clinical Presentation 0.27-0.40% of all congenital cardiac defects 0.08-0.30% of patients undergoing coronary angiography PE – continuous murmur Clinical Presentation >50% of patients are asymptomatic Most patients have small Qp/Qs, normal pulmonary and systemic pressures at time of diagnosis Occurrence of symptoms correlates with larger shunts In patients with CAD, even small Qp/Qs can exacerbate angina Symptoms and complications are rare in young patients but increase significantly with age.

Coronary Fistulas Potential Complications Clinical Course Management Angina (coronary steal) Congestive heart failure Rupture Myocardial Infarction SBE Clinical Course Most untreated patients will develop symptoms and/or fistula related complications Surgical ligation at an older age is associated with increased morbidity and mortality Management Elective closure/ligation is recommended in most patients

Case Patient referred for percutaneous closure of the A-V fistulas. Attempts at coil embolization were unsuccessful due to the serpiginous nature of the fistulous tracks.

What would be your next recommendation?

Case – (L & R coronary fistulas appeared to share a common ampulla)

Amplatzer Vascular Plug (AVP) (AGA Medical Corp Amplatzer Vascular Plug (AVP) (AGA Medical Corp., Golden Valley, Minnesota, USA) Designed for treatment of A-V fistulas and other malformation of the peripheral vasculature Nitinol Mesh Self expanding Diameter sizes 2-16mm Length 7-8 mm Preloaded and attached to delivery cable (135 cm) Delivered through standard 5-8F coronary guiding catheter

Case – LHC (2nd catheter in PA)

Case – Amplatzer Vascular Plug

Case AR1 guiding catheter through the RFV Angiographic measurements revealed an ampulla with a diameter of 11mm and neck of 7mm 12 mm AVP device was placed Heparin was reversed with protamine

Final Results

Final Results

Final Results

Summary Elective closure of coronary artery fistulas is recommended in most patients due to risk of complications with advancing age Amplatzer Vascular Plug is an easy and safe alternative to surgery or coil embolization