Informação da revista
Vol. 33. Núm. 2.
Páginas 119-121 (Fevereiro 2014)
Partilhar
Partilhar
Baixar PDF
Mais opções do artigo
Vol. 33. Núm. 2.
Páginas 119-121 (Fevereiro 2014)
Image in Cardiology
Open Access
Multiple coronary fistulae: Characterization by multimodality imaging
Fístulas coronárias múltiplas – relevância da multimodalidade imagiológica
Visitas
6269
Carla Sousaa,
Autor para correspondência
cmcsousa@gmail.com

Corresponding author.
, Elisabete Martinsa, Teresa Pinhoa, Mariana Vasconcelosa, Manuel Campeloa, António J. Madureirab, Rui Rodriguesa, Inês Rangela, Alexandra Gonçalvesa, Filipe Macedoa, Maria Júlia Maciela
a Cardiology Department, Centro Hospitalar de São João, Porto, Portugal; Faculdade de Medicina da Universidade do Porto, Porto, Portugal
b Radiology Department, Centro Hospitalar de São João, Porto, Portugal
Este item recebeu

Under a Creative Commons license
Informação do artigo
Texto Completo
Baixar PDF
Estatísticas
Figuras (2)
Material adicional (4)
Texto Completo

A 63‐year‐old man was admitted for non‐ST‐elevation myocardial infarction. Echocardiography showed preserved biventricular systolic function with apical hypokinesia. Apical 4‐chamber color Doppler view revealed abnormal diastolic flow, apparently intramyocardial (Figure 1A and Video 1). Coronary angiography revealed moderate (60%) coronary stenosis in the mid right coronary artery (Figure 1B), with a fractional flow reserve of 0.91, compatible with a functionally non‐significant lesion. Multiple small fistulae originating from both the right and left coronary arteries were observed, draining into the left ventricle (Figure 1B and C and Videos 2 and 3). Cardiac magnetic resonance imaging (MRI) provided further characterization of these fistulae, which were visible in T2‐weighted sequences in short axis view in the anterior and posterior interventricular grooves (Figure 2A). First‐pass myocardial rest perfusion imaging in two‐chamber view revealed epicardial hyperenhancement of the anterior wall simultaneous with aortic opacification (Figure 2B and Video 4), as well as earlier perfusion of the mid and apical anterior segments. There was subendocardial late gadolinium enhancement (LGE) in the apical inferior segment, compatible with non‐transmural myocardial infarction (Figure 2C). Dobutamine stress echocardiography under optimized therapy showed no inducible ischemia and the patient was discharged, and has remained stable ever since, now at two‐year follow‐up.

Figure 1.

(A) Two‐dimensional echocardiography in 4‐chamber color Doppler view showing abnormal intramyocardial diastolic flow in the apical lateral segment (arrow); (B) selective right coronary angiography showing 60% stenosis in the mid right coronary artery and multiple coronary fistulae arising from its distal segment and draining into the left ventricle (arrow); (C) selective left coronary angiography showing multiple coronary fistulae arising from the distal segments of the left coronary artery, also draining into the left ventricular cavity (arrow).

(0,13MB).
Figure 2.

(A) Short‐axis T2‐weighted images with multiple unexpected small vascular structures in the anterior and posterior interventricular grooves; (B) first‐pass myocardial rest perfusion imaging in 2‐chamber view, showing epicardial hyperenhancement of the anterior wall simultaneous with aortic opacification (left) and earlier perfusion of the mid and apical anterior segments (right); (C) subendocardial late gadolinium enhancement in the apical inferior myocardial segment, in 4‐chamber and 2‐chamber views.

(0,21MB).

Multiple coronary fistulae constitute a very rare entity and probably correspond to the persistence of embryonic myocardial sinusoids. They are an uncommon cause of subendocardial ischemia, due to a coronary steal phenomenon.

This case highlights the role of multimodality imaging in the presence of such coronary anomalies: echocardiography raised the suspicion, coronary angiography made the diagnosis and cardiac MRI provided further characterization of anatomy, physiology (rest perfusion) and myocardial structure (LGE).

To our knowledge this is the first report describing the anatomical appearance of multiple coronary fistulae in T2‐weighted images as well as their peculiar pattern on first‐pass myocardial rest perfusion imaging.

Ethical disclosuresProtection of human and animal subjects

The authors declare that no experiments were performed on humans or animals for this study.

Confidentiality of data

The authors declare that they have followed the protocols of their work center on the publication of patient data and that all the patients included in the study received sufficient information and gave their written informed consent to participate in the study.

Right to privacy and informed consent

The authors have obtained the written informed consent of the patients or subjects mentioned in the article. The corresponding author is in possession of this document.

Conflicts of interest

The authors have no conflicts of interest to declare.

Appendix A
Supplementary data

The following are the supplementary data to this article:

(0,28MB)

4‐Chamber apical echocardiographic view revealing mild left atrial enlargement and normal sized ventricles with preserved systolic function. Abnormal intramyocardial diastolic flow is seen in the apical lateral segment.

(1,42MB)

Selective right coronary artery angiography revealing 60% stenosis in the mid segment and multiple coronary fistulae arising from the distal segment and draining into the left ventricle.

(1,52MB)

Selective left coronary artery angiography revealing a network of coronary fistulae arising from distal segments of the left anterior descending and circumflex coronary arteries, all draining into the left ventricle.

(0,66MB)

First‐pass myocardial rest perfusion imaging revealing anterior wall epicardial hyperenhancement simultaneous with aortic opacification and earlier perfusion of the mid and apical myocardial segments of the anterior wall.

Copyright © 2013. Sociedade Portuguesa de Cardiologia
Idiomas
Revista Portuguesa de Cardiologia
Opções de artigo
Ferramentas
Material Suplementar
en pt

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos

Ao assinalar que é «Profissional de Saúde», declara conhecer e aceitar que a responsável pelo tratamento dos dados pessoais dos utilizadores da página de internet da Revista Portuguesa de Cardiologia (RPC), é esta entidade, com sede no Campo Grande, n.º 28, 13.º, 1700-093 Lisboa, com os telefones 217 970 685 e 217 817 630, fax 217 931 095 e com o endereço de correio eletrónico revista@spc.pt. Declaro para todos os fins, que assumo inteira responsabilidade pela veracidade e exatidão da afirmação aqui fornecida.