Challenging Case of Percutaneous Closure of Right Coronary Artery to Right Atrial Fistula

J INVASIVE CARDIOL 2020;32(9):E246-E247. 

Key words: coronary artery fistula, transcatheter device closure

A 5-year-old boy underwent echocardiography for evaluation of a systolic murmur; it revealed a diffuse dilation of the right coronary artery (RCA) with a 3 mm restrictive fistulous opening below the ostium of the coronary sinus and normal biventricular function (Figure 1A). Cardiac catheterization was performed for fistula closure via the femoral approach. This revealed normal right heart and mildly elevated left ventricular end-diastolic pressures, with a pulmonary to systemic blood flow ratio of 1.6.

Angiography of the aortic root demonstrated a markedly dilated RCA with a fistulous connection of the right atrium (Figure 1B). Selective injection of the fistula was performed using a 4 Fr angled Glide catheter (Terumo Medical), demonstrating a fistulous connection of the distal portion of the RCA that entered a saccular area measuring about 8 mm and distal narrowing to about 3 mm at the inferior portion of the right atrium (Figure 1C). Using the 4 Fr angled Glide catheter and a microcatheter, we gained access to the saccular portion of the fistula. Multiple attempts were made to deliver a 12 mm x 40 cm Ruby detachable coil (Penumbra); however, this was technically unsuccessful (Figure 1D). We subsequently elected to use an 8 mm Amplatzer Vascular Plug (Abbott Vascular) for fistula closure. 

The device was delivered in standard fashion and ultimately lodged in the proximal portion of the fistula. An angiogram after placement (but before release) revealed the device to be in good position without occlusion of any coronary artery branches (Figure 1E). After 15 minutes, there were no blood pressure changes or electrocardiographic changes. The device was thereafter released and a final angiogram was obtained that demonstrated complete occlusion of the fistula (Figure 1F; Video 1). We demonstrate the challenges of percutaneous closure of a coronary fistula and the subsequent utilization of a vascular plug in a patient with challenging anatomy.

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From the ¹Department of Cardiovascular Diseases, Mayo Clinic, Phoenix, Arizona; and ²Department of Cardiology, Phoenix Children’s Hospital, Phoenix, Arizona.

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.

The authors report that patient consent was provided for publication of the images used herein.

Manuscript accepted December 11, 2019.

Address for correspondence: Pradyumna Agasthi, MD, Department of Cardiovascular Diseases, Mayo Clinic, 5779 East Mayo Blvd, Phoenix, AZ 85054. Email: pradyumna_agasthi@hotmail.com