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Coronary artery fistula and premature coronary atherosclerosis

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Address for correspondence: Łukasz Turek, 2nd Department of Cardiology, Swietokrzyskie Cardiology Center, ul. Grunwaldzka 45, 25–736 Kielce, Poland, tel: +48 692199654, e-mail: garbit.garbit@interia.pl

Received: 24.11.2018 Accepted: 4.02.2019

Coronary artery fistula and premature coronary atherosclerosis

Łukasz Turek

1

, Anna Polewczyk

1, 2

, Marianna Janion

1, 2

, Marcin Sadowski

2, 3

12nd Department of Cardiology, Swietokrzyskie Cardiology Center, Kielce, Poland

2Medical Faculty and Health Sciences, The Jan Kochanowski University, Kielce, Poland

3Catheterization Laboratory, Swietokrzyskie Cardiology Center, Kielce, Poland

A 48-year-old man with insignificant family history and without cardiovascular risk factors was admitted due to typical retrosternal chest pain of 30 min duration. Physical examination was within normal limits. Transthoracic echocardiography revealed anterior wall basal segments hypokinesis.

Signs of ongoing myocardial ischemia in admission electrocardiogram (ST-segment depression in V1–V4) together with a significant rise in cardiac troponin T level (from 4.9 to 143.4 ng/L) resulted in a diagnosis of acute coronary syndrome without ST-segment elevation as most probable. Coronary angiography revealed a critical stenosis of a marginal branch (Fig. 1A) and coronary artery fistula (CAF) originat- ing from the left main coronary artery (Fig. 1C, D).

A successful percutaneous coronary intervention of the marginal branch with drug-eluting stent im- plantation was performed (Fig. 1B). The patient’s further recovery was uneventful. A repeat careful echocardiographic examination was able to detect flow to the right pulmonary artery (Fig. 1E, F).

Moreover, diameter measurements of cardiac

chambers, pulmonary and systemic flow ratios (Qp/

/Qs) and systolic pulmonary artery pressure deter- mined by Doppler echocardiography were normal.

Multidetector computed tomography is commonly used to detect and enhance visualization of the complex geometry of coronary fistulas, however, in this case the computed tomography scan was not performed related to an absence of pressure and volume overload on echocardiographic study, the patient was asymptomatic with CAF (unexplained relation of CAFs to incidence of atherosclerotic coronary artery disease) and radiological protec- tion. This patient was recommended conservative management of CAF as the first-line treatment option and further follow-up. CAF is a rare vascular anomaly with an estimated prevalence of 0.002%

in the general population and it can reach up to 5%

in patients undergoing coronary angiography. In adults, about 30% of CAF cases are associated with coronary atherosclerosis — however, the relation- ship between CAFs and coronary atherosclerosis has not yet been clarified.

Conflict of interest: None declared INTERVENTIONAL CARDIOLOGY

Cardiology Journal 2019, Vol. 26, No. 3, 296–297

DOI: 10.5603/CJ.2019.0059 Copyright © 2019 Via Medica

ISSN 1897–5593

296 www.cardiologyjournal.org

IMAGE IN CARDIOVASCULAR MEDICINE

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Figure 1. A. Coronary angiography: critical stenosis of the marginal branch (arrow); B. Coronary angiography: suc- cessful percutaneous coronary intervention of marginal branch (arrow); C, D. Coronary angiography: coronary artery fistula (CAF; arrow); E. Echocardiography study — suprasternal view of long axis of right pulmonary artery (RPA)

— color flow Doppler images: CAF flow (arrow); F. Echocardiography study — suprasternal view of long axis of RPA

— pulsed-wave Doppler: CAF flow (arrow) — sample volume in the RPA; Ao — aortic arch.

www.cardiologyjournal.org 297

Łukasz Turek et al., Coronary artery fistula and premature coronary atherosclerosis

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