Diffuse Coronary-Cameral Fistulae Observed via an Ultrasound Contrast Agent (Definity)

Video 1. An ultrasound contrast agent (Definity, Lantheus Medical Imaging) was injected into the first septal perforator. This caused the area of myocardium supplied by the engaged septal perforator to enhance on the echocardiographic images, thus localizing the myocardium targeted for ablation. However, shortly after injection of the echo contrast agent, jets of contrast were observed emanating from the septal wall into the LV cavity.

Case: A 40-year-old male with known hypertrophic cardiomyopathy presented with persistent symptoms of chest pain, dyspnea and syncope, despite good medical therapy. Vitals were normal and physical exam did not reveal any resting murmurs or precordial heaves. But a harsh 2/6 systolic murmur could be auscultated at the right sternal border with Valsalva. 

Echo revealed a 69% ejection fraction and 28-mm-thick septum with signs of left ventricular outflow tract obstruction. Catheterization revealed normal coronaries and confirmed a significant gradient of 135mmHg after induction of a premature ventricular contraction. After discussing treatment options, the patient opted for percutaneous alcohol septal ablation. However, after balloon isolation of septal perforating arteries and injection of Lipid Microsphere Echo Contrast (which localizes the myocardium for ablation via TEE guidance), the contrast was seen jetting freely from the septum into the ventricular cavities. The phenomenon was observed regardless of the perforator isolated. A diagnosis of extensive congenital coronary cameral fistulae was made and due to concerns of the possible effects of escaping alcohol on the patient‚Äôs downstream vasculature and organs, the ablation was aborted and he was referred for surgical myomectomy. Our literature review did not find any cases of coronary cameral fistulae being documented in this manner. Our novel method allows for real-time conception of flow through the cameral fistulae, without relying on color extrapolation used in traditional echo modalities.

From: Septal Sobriety: Aborted Alcohol Septal Ablation for Hypertrophic Cardiomyopathy Secondary to Diffuse Coronary-Cameral Fistulae

Authors: Loren Garrison Morgan, MD, Arun Kumar Nagabandi, MBBS, Paul Poommipanit, MD, FACC, FSCAI, The Medical College of Georgia at Georgia Regents University, Department of Internal Medicine, Section of Cardiology, Augusta, Georgia

Original article link: http://www.cathlabdigest.com/article/Septal-Sobriety-Aborted-Alcohol-Septal-Ablation-Hypertrophic-Cardiomyopathy-Secondary