Transcatheter closure of large fistula between right coronary artery and pulmonary artery using Amplatzer vascular plug in a patient with pulmonary atresia and ventricular septal defect / Pulmoner atrezi--ventrikuler septal defekt olgusunda sag koroner arter pulmoner arter arasindaki fistulun transkateter olarak Amplatzer vaskuler tikac ile kapatilmasi.

A 38-year-old man was admitted with pretibial edema, exertional dyspnea, chest pain and cyanosis. On physical examination there was a loud, single second heart sound. A continuous murmur best heard at left second intercostal space radiating to the back was appreciated. Pulse oxymetric oxygen saturation was 85%. Chest X-Ray showed cardiomegaly. The electrocardiogram demonstrated right axis deviation with right ventricular (RV) hypertrophy. Transthoracic echocardiography revealed an overriding aorta with no continuity between RV outflow tract and pulmonary artery (PA), PA branches were confluent and fed by aortopulmonary collaterals. It also revealed enlarged end-systolic and end-diastolic dimensions of both ventricles with reduced fractional shortening (14%) and ejection fraction (30%) of left ventricle. Myocardial perfusion scintigraphy with thallium-201 demonstrated perfusion defects in right coronary artery (RCA) territory. Angiography showed the presence of a large fistula between the RCA and main PA (Fig. 1, Video 1. See corresponding video/movie images at www.anakarder.com).

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A 6 French guiding catheter was introduced into RCA. A 0.018" nitinol guidewire was advanced into the fistula and further into the PA. A 10 mm Amplatzer vascular occluder was then positioned within the fistula and released without complication (Fig. 2, Video 2. See corresponding video/movie images at www.anakarder.com). Post deployment angiography showed no residual shunting (Fig. 3, Video 3. See corresponding video/movie images at www.anakarder.com).

Coronary artery fistula caused both congestive heart failure and myocardial ischemia leading to severe myocardial systolic dysfunction. Because of severely depressed LV systolic function patient was thought to be a poor candidate for corrective surgery. Transcatheter closure of the coronary fistula relieved symptoms of congestive heart failure gradually and improved fractional shortening (24%) and ejection fraction (46%).

Address for Correspondence/Yazisma Adresi: Dr. Abdullah Erdem Basaksehir 4. Etap 1. Kisim D:28 No:18 Esenler, Istanbul, Turkey E-mail: [e-mail]

Ahmet Celebi, Yalim Yalcin, Cenap Zeybek, Abdullah Erdem, Tugcin Bora Polat, Celal Akdeniz

Clinic of Pediatric Cardiology, Dr. Siyami Ersek Thorax and Cardiovascular Surgery Education and Research Hospital, Istanbul, Turkey