A Bleeding Heart: Coronary-Cameral Fistula After Septal Myomectomy

J INVASIVE CARDIOL 2017;29(12):E199-E200.

Key words: hypertrophic cardiomyopathy, cardiac imaging

Coronary-cameral fistulas (CCFs) are relatively rare communications arising within the coronary vasculature entering into one of the four cardiac chambers. They are categorized as congenital or acquired, and have been reported as occurring after such insults as trauma, myocardial infarction, and ventricular myomectomy (as discussed in the current report).^1-4 Older literature reports under 3% of CCFs communicating with the left ventricle; however, prospective studies after septal myomectomy for hypertrophic cardiomyopathy (HCM) have reported the incidence as high as nearly 25%, with resolution in the majority of patients within 6 months.^3,4 As such, there is no clearly agreed upon treatment recommended. We present an impressive example of a patient with multiple CCFs after septal myomectomy for HCM. 

The patient is a 44-year-old woman with a history of HCM. She presented to our cardiovascular center 1 month after undergoing septal myomectomy for HCM along with repair of an apical aneurysm with thrombus evacuation; her surgery had been deemed a success, with reduction in left ventricular septal size from 30 mm to 8 mm and complete elimination of obstructive gradient. In the month after her surgery, she developed progressive exertional dyspnea, dependent edema, and orthopnea. She was admitted and a repeat echocardiogram demonstrated a reduction in left ventricular ejection fraction to 25% from a previous 60%, along with a diastolic flow signal emanating from the ventricular septum (Figure 1). The patient subsequently underwent coronary angiography. This demonstrated numerous CCFs involving the left anterior descending and first diagonal arteries (Figure 2), as well as the right posterior descending artery (Figure 3). No significant coronary artery disease was noted. No intervention was performed. The patient was subsequently started on neurohormonal blockade for newly diagnosed heart failure and discharged with referral to the Advanced Heart Failure service for continued care.

This case highlights a striking angiographic example of CCF occurring after septal myomectomy, a complication occurring somewhat frequently with typical spontaneous resolution.

References

1.    Ryan C, Gertz EW. Fistula from coronary arteries to left ventricle after myocardial infarction. Br Heart J. 1977;39:1147-1149.

2.    Lowe JE, Adams DH, Cummings RG, Wesly RLR, Philips HR. The natural history and recommended management of patients with traumatic coronary artery fistulas. Ann Thorac Surg. 1983;36:295-305. 

3.    Jebara VA, Corbi P, Dreyfus G, et al. Fistule coronaroventriculaire iatrogenique postoperatoire. Ann Chir Thorac Cardiovasc. 1989;43:643-645.

4.    Sgalambro A, Olivotto I, Rossi A, et al. Prevalence and clinical significance of acquired left coronary artery fistulas after surgical myomectomy in patients with hypertrophic cardiomyopathy. J Thorac Cardiovasc Surg. 2010;140:1046-1052.

From the Department of Cardiovascular Medicine, UC San Diego Health System, San Diego, California. 

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.

Manuscript accepted May 10, 2017.

Address for correspondence: Daniel Walters, MD, UC San Diego Health System, Sulpizio Cardiovascular Center, 9434 Medical Center Drive, La Jolla, CA 92037 Email: dcwalters@ad.ucsd.edu