Author + information
- Philipp Brantner, MDa,
- Antonio Madaffari, MDb,c,
- Gregor Fahrni, MDb,c,
- Michael J. Zellweger, MDb,c and
- Philip Haaf, MDb,c,∗ ()
- aDepartment of Radiology, 3D PrintLab, University Hospital Basel, University of Basel, Basel, Switzerland
- bDepartment of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- cCardiovascular Research Institute Basel, University Hospital Basel, University Basel, Basel, Switzerland
- ↵∗Address for correspondence:
Dr. Philip Haaf, Department of Cardiology, University Hospital Basel, Petersgraben 4, CH-4031, Basel, Switzerland.
In a 32-year-old patient with chest pain, a large, complex coronary-venous fistula with additional feeders from the descending aorta was detected with computed tomography. Multimodality imaging, including multicolor 3-dimensional printing, allowed precise anatomic visualization of the origin, course and drainage site of the fistula. The patient was treated conservatively. (Level of Difficulty: Advanced.)
- binder-jetting technology
- computed tomography
- coronary artery fistula
- multicolor 3-dimensional printed model
A 32-year-old patient presented with acute chest pain, diffuse ST-segment elevation on the electrocardiogram, and elevated cardiac troponin. Coronary angiography excluded stenosis of the epicardial vessels but showed an ectatic left main coronary artery with suspicion of a coronary fistula (Figure 1A, Video 1).
For better anatomic visualization and assessment of hemodynamic significance a cardiac computed tomography (CT) scan was performed. A large coronary-venous fistula (maximum diameter 8 mm) arising from the proximal circumflex artery, running between the left ventricular outflow tract and the anterior wall of the left atrium and draining into the superior vena cava, was shown (Central Illustration A, Figure 1B, Video 2). In addition, a small vessel originated from the descending aorta and bifurcated into 2 branches: 1 running superior and 1 inferior to the left pulmonary artery (Central Illustration B, Figure 1C, Video 3). The 2 branches rejoined and drained into the distal part of the coronary-venous fistula. For further spatial assessment of the complex vessel anatomy a multicolor 3-dimensional (3D) printed model, using binder-jetting technology, was created (Figure 1D, Video 4). This technology allows creating a multicolored 3D model, while also identifying small substructures such as the fistula origin and adjacent arteries, which would be essential for a safe interventional or surgical treatment (1). A coronary aneurysm or dilatation of right chambers, as indirect sign of hemodynamic relevance, could be excluded. Furthermore, echocardiographically, there was no evidence of an elevated pulmonary artery pressure; a cardiac magnetic resonance scan showed a pattern of acute myocarditis without evidence of myocardial infarction with normal biventricular dimensions, equal and normal biventricular stroke volumes, as well as aortic and pulmonary flow volumes. Therefore, the patient was treated conservatively.
Coronary fistulae are rare, primarily congenital abnormal communications between coronary arteries and another cardiovascular structure without an interposed capillary bed ranging from 0.05% to 0.9% in several large selected series (2). Clinically, the drainage site of a fistula is more important than its origin; coronary cameral fistulae terminate in a cardiac chamber (commonly into low-pressure right-side cardiac structures), and coronary arteriovenous fistulae terminate into a venous structure such as venae cavae, coronary sinus, bronchial veins, and pulmonary arteries (2).
Recent guidelines have toned down indications for surgical or interventional repair and considered the elevated risk (11%) of post-operative myocardial infarction, for example, due to slow flow phenomenon in the dilated coronary artery proximal to the fistula, coronary dissection, or spasm, as well as thrombosis or device embolization leading to a reduced late survival (3). In general, presence of large, symptomatic coronary fistulae—with evidence of ischemia by steal phenomenon—require review by a knowledgeable multidisciplinary heart team to determine the role of medical therapy and/or percutaneous or surgical closure (3). Most coronary fistulae, however, are small, do not compromise myocardial blood flow, and are incidental findings.
Multiplanar reconstruction with 3D volume-rendered imaging yields precise anatomic visualization of the size, origin, course and drainage site of the fistula; 3D printing may enhance visuospatial appreciation of the vascular anomaly, in particular with cases of complex anomalies with tortuosity, multiple origin, and drainage sites. A tangible heart model by 3D printing of complex coronary fistulae may be instrumental before interventions or surgery in treatment planning to improve sizing or designing of patient-specific devices. It may be helpful for intraoperative orientation, have educational value, and may be used in communication of the pathology with the affected patient (1).
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the JACC: Case Reports author instructions page.
- Abbreviations and Acronyms
- computed tomography
- Received February 25, 2020.
- Revision received May 21, 2020.
- Accepted June 15, 2020.
- 2020 The Authors
- Bartel T.,
- Rivard A.,
- Jimenez A.,
- Mestres C.A.,
- Müller S.
- Stout K.K.,
- Daniels C.J.,
- Aboulhosn J.A.,
- et al.