Prevalence and clinical significance of acquired left coronary artery fistulas after surgical myectomy in patients with hypertrophic cardiomyopathy Aurelio.

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Presentation transcript:

Prevalence and clinical significance of acquired left coronary artery fistulas after surgical myectomy in patients with hypertrophic cardiomyopathy Aurelio Sgalambro, MD, Iacopo Olivotto, MD, Alessandra Rossi, MD, Stefano Nistri, MD, Katia Baldini, MD, Massimo Baldi, MD, Pierluigi Stefano, MD, David Antoniucci, MD, Francesca Garbini, MD, Franco Cecchi, MD, Magdi H. Yacoub, MD, FRS The Journal of Thoracic and Cardiovascular Surgery Volume 140, Issue 5, Pages 1046-1052 (November 2010) DOI: 10.1016/j.jtcvs.2010.02.020 Copyright © 2010 The American Association for Thoracic Surgery Terms and Conditions

Figure 1 Echocardiographic diagnosis of acquired septal left coronary artery fistulas (LCAFs) after surgical myectomy. The required criteria for LCAF diagnosis used in the present study are shown. A, In the magnified left parasternal long-axis view, an LCAF, originating from the ventricular septum (IVS) and draining in the outflow tract (yellow arrow), is evident and easily differentiated from a mild aortic regurgitation jet (red arrow). Ao, Aorta; LA, left atrium. B, Continuous-wave Doppler scanning recorded a holodiastolic flow, with a maximal velocity of 3.17 m/s (peak gradient, 42 mm Hg). C and D, Color M-mode scanning: LCAF flow bordered the left septal endocardial surface (C, yellow arrow), whereas the aortic regurgitation was situated in the center of the outflow tract (D, red arrow). The Journal of Thoracic and Cardiovascular Surgery 2010 140, 1046-1052DOI: (10.1016/j.jtcvs.2010.02.020) Copyright © 2010 The American Association for Thoracic Surgery Terms and Conditions

Figure 2 Intraoperative aspect of a large left coronary artery fistula generated during surgical myectomy conducted through the transaortic and transapical approaches for severe midventricular obstruction. Intraoperative selective intracoronary injection showed abundant flow originating from a large perforator branch (arrow). This fistula was surgically closed, and no shunt resulted at postoperative echocardiographic analysis. The Journal of Thoracic and Cardiovascular Surgery 2010 140, 1046-1052DOI: (10.1016/j.jtcvs.2010.02.020) Copyright © 2010 The American Association for Thoracic Surgery Terms and Conditions

Figure 3 Multiple left coronary artery fistulas (LCAFs) in a 31-year old man with hypertrophic cardiomyopathy operated on from both the transaortic and apical approaches for severe midventricular obstruction. Multiple small LCAFs (arrows) draining in the left ventricular cavity were documented, originating from the apex (A–C), lateral wall (D–F, H, and I), and anterolateral papillary muscle (G). Continuous-wave Doppler ultrasound flow velocity recording showed maximal velocities ranging from 1.48 to 1.74 m/s, which are equivalent to a pressure decrease from 9 to 11 mm Hg (C, F, and I). Flow began at the end of isovolumic relaxation and lasted for the rest of diastole. All LCAFs spontaneously healed within 2 months from surgical intervention. The Journal of Thoracic and Cardiovascular Surgery 2010 140, 1046-1052DOI: (10.1016/j.jtcvs.2010.02.020) Copyright © 2010 The American Association for Thoracic Surgery Terms and Conditions

Figure 4 Large persistent left coronary artery fistulas (LCAFs) in a 72-year-old woman with hypertrophic cardiomyopathy with prior alcohol septal ablation. A magnified, apical 4-chamber off-axis view (A) and a subcostal, 4-chamber off-axis view (B) show wide, red-encoded flow entering the left ventricular cavity from the anterior wall (yellow arrows) caused by LCAFs that is easily differentiated from a mild aortic regurgitation jet simultaneously present in the left ventricular outflow tract (LVOT). The jet shows substantial variance, reflecting high-velocity flow. IVS, Interventricular septum; Ao, aorta; RA, right atrium; RV, right ventricle; LV, left ventricle. Continuous-wave Doppler recordings (C and D) showed high maximal early diastolic velocity of 4.33 m/s (a derived pressure decay of 73 mm Hg) compared with 3.18 m/s for the aortic regurgitation jet. A coronary angiogram confirmed the presence of a large first septal perforator branch fistula spraying in the left ventricular cavity (E, arrow). The Journal of Thoracic and Cardiovascular Surgery 2010 140, 1046-1052DOI: (10.1016/j.jtcvs.2010.02.020) Copyright © 2010 The American Association for Thoracic Surgery Terms and Conditions