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Spontaneous closure of iatrogenic coronary artery fistula to left ventricle after septal myectomy for hypertrophic obstructive cardiomyopathy.

Choi YJ, You CW, Park MK, Park JI, Kwon SU, Lee SC, Lee HJ, Park SW - J. Korean Med. Sci. (2006)

Bottom Line: A 46-yr-old woman was hospitalized for evaluation of chest pain and shortness of breath for 3 months.Postoperative color Doppler imaging revealed a diastolic blood flow from the interventricular septal myocardium to the left ventricular cavity, i.e. iatrogenic coronary artery fistula to the left ventricle.Ten days later, the fistula closed spontaneously which was diagnosed by transthoracic echocardiography and confirmed by coronary angiography.

View Article: PubMed Central - PubMed

Affiliation: Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.

ABSTRACT
Cases of iatrogenic coronary artery fistulas draining into the left ventricle after surgical myectomy for hypertrophic obstructive cardiomyopathy have been published as sporadic reports. However, its management scheme and prognosis are not clear because of the low incidence. A 46-yr-old woman was hospitalized for evaluation of chest pain and shortness of breath for 3 months. Transthoracic echocardiographic examination showed typical hypertrophic obstructive cardiomyopathy with a peak pressure gradient of 71 mmHg across the left ventricular outflow tract. The patient underwent surgical septal myectomy. Postoperative color Doppler imaging revealed a diastolic blood flow from the interventricular septal myocardium to the left ventricular cavity, i.e. iatrogenic coronary artery fistula to the left ventricle. Ten days later, the fistula closed spontaneously which was diagnosed by transthoracic echocardiography and confirmed by coronary angiography.

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Hypertrophied basal septal wall (A) was reduced in thickness after surgical septal myectomy (B). Arrowheads indicate the site of myectomy.
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Figure 3: Hypertrophied basal septal wall (A) was reduced in thickness after surgical septal myectomy (B). Arrowheads indicate the site of myectomy.

Mentions: A 46-yr-old woman was hospitalized for evaluation of chest pain and shortness of breath that began three months ago. She had recurrent episodes of anterior chest pain, which was relieved by sublingual nitroglycerin. On physical examination, her blood pressure was 130/70 mmHg, pulse rate 54 beats per minute, respiratory rate 20 per minute, and body temperature 36℃. Jugular venous engorgement was not found. A grade III systolic murmur was audible on her left lower sternal border. The lung sounds were clear. Mild pretibial pitting edema was found in both lower extremities. Electrocardiogram revealed regular sinus rhythm and left ventricular hypertrophy with strain pattern (Fig. 1). Chest radiograph showed moderate cardiomegaly without pulmonary edema (Fig. 2). On peripheral blood test, WBC count was 7,590/µL, hemoglobin 12.0 g/dL, platelet count 291,000/µL, serum total protein 6.2 g/dL, albumin 4.1 g/dL, and N-terminal proBNP 3,800 pg/mL. Arterial blood gas analysis and other biochemical tests were normal. Preoperative coronary angiography revealed no stenosis or abnormal connections of the coronary arteries. Transthoracic echocardiography demonstrated diffuse concentric hypertrophy of the ventricular myocardium, which was predominant in the septum (Fig. 3). The septal wall thickness was 31 mm and the posterior wall thickness was 12 mm, and the ejection fraction was normal. No regional wall motion abnormalities were found. Systolic anterior motion of the mitral valve leaflets (SAM) with moderate amount of mitral regurgitation and mid-systolic closure of the aortic valve were observed. Resting peak pressure gradient in the left ventricular outflow tract (LVOT) was 71 mmHg, and it increased up to 114 mmHg with Valsalva maneuver. Left atrial enlargement and moderate pulmonary hypertension were also noted.


Spontaneous closure of iatrogenic coronary artery fistula to left ventricle after septal myectomy for hypertrophic obstructive cardiomyopathy.

Choi YJ, You CW, Park MK, Park JI, Kwon SU, Lee SC, Lee HJ, Park SW - J. Korean Med. Sci. (2006)

Hypertrophied basal septal wall (A) was reduced in thickness after surgical septal myectomy (B). Arrowheads indicate the site of myectomy.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC2721939&req=5

Figure 3: Hypertrophied basal septal wall (A) was reduced in thickness after surgical septal myectomy (B). Arrowheads indicate the site of myectomy.
Mentions: A 46-yr-old woman was hospitalized for evaluation of chest pain and shortness of breath that began three months ago. She had recurrent episodes of anterior chest pain, which was relieved by sublingual nitroglycerin. On physical examination, her blood pressure was 130/70 mmHg, pulse rate 54 beats per minute, respiratory rate 20 per minute, and body temperature 36℃. Jugular venous engorgement was not found. A grade III systolic murmur was audible on her left lower sternal border. The lung sounds were clear. Mild pretibial pitting edema was found in both lower extremities. Electrocardiogram revealed regular sinus rhythm and left ventricular hypertrophy with strain pattern (Fig. 1). Chest radiograph showed moderate cardiomegaly without pulmonary edema (Fig. 2). On peripheral blood test, WBC count was 7,590/µL, hemoglobin 12.0 g/dL, platelet count 291,000/µL, serum total protein 6.2 g/dL, albumin 4.1 g/dL, and N-terminal proBNP 3,800 pg/mL. Arterial blood gas analysis and other biochemical tests were normal. Preoperative coronary angiography revealed no stenosis or abnormal connections of the coronary arteries. Transthoracic echocardiography demonstrated diffuse concentric hypertrophy of the ventricular myocardium, which was predominant in the septum (Fig. 3). The septal wall thickness was 31 mm and the posterior wall thickness was 12 mm, and the ejection fraction was normal. No regional wall motion abnormalities were found. Systolic anterior motion of the mitral valve leaflets (SAM) with moderate amount of mitral regurgitation and mid-systolic closure of the aortic valve were observed. Resting peak pressure gradient in the left ventricular outflow tract (LVOT) was 71 mmHg, and it increased up to 114 mmHg with Valsalva maneuver. Left atrial enlargement and moderate pulmonary hypertension were also noted.

Bottom Line: A 46-yr-old woman was hospitalized for evaluation of chest pain and shortness of breath for 3 months.Postoperative color Doppler imaging revealed a diastolic blood flow from the interventricular septal myocardium to the left ventricular cavity, i.e. iatrogenic coronary artery fistula to the left ventricle.Ten days later, the fistula closed spontaneously which was diagnosed by transthoracic echocardiography and confirmed by coronary angiography.

View Article: PubMed Central - PubMed

Affiliation: Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.

ABSTRACT
Cases of iatrogenic coronary artery fistulas draining into the left ventricle after surgical myectomy for hypertrophic obstructive cardiomyopathy have been published as sporadic reports. However, its management scheme and prognosis are not clear because of the low incidence. A 46-yr-old woman was hospitalized for evaluation of chest pain and shortness of breath for 3 months. Transthoracic echocardiographic examination showed typical hypertrophic obstructive cardiomyopathy with a peak pressure gradient of 71 mmHg across the left ventricular outflow tract. The patient underwent surgical septal myectomy. Postoperative color Doppler imaging revealed a diastolic blood flow from the interventricular septal myocardium to the left ventricular cavity, i.e. iatrogenic coronary artery fistula to the left ventricle. Ten days later, the fistula closed spontaneously which was diagnosed by transthoracic echocardiography and confirmed by coronary angiography.

Show MeSH
Related in: MedlinePlus