February 1997 2 6 0 Youssef Schob, and Kessler American Heart Journal

and the use of superoinferior sweeps from the high left paras ternal and suprasternal t ransducer positions. These sweeps demonstrate the spatial relationship of the origins and courses of the branch pulmonary arteries. Accurate noninvasive diagnosis of pulmonary artery malpositions can be made with echocardiography. The finding of crossed pulmonary arteries may be a clue for the presence ofasso- da ted cardiac and extracardiac anomalies.

REFERENCES

1. Becker AE, Becker MJ, Edwards JE. Malposition of pulmonary art- eries (crossed pulmonary arteries) in persistent truncus arteriosus. AJR Am J Roentgenol 1970;110:509-14.

2. Jue KL, Lockman LA, Edwards JE. Anomalous origins of pulmonary arteries from pulmonary trunl~. ("crossed pulmonary arteries"). Am Heart J 1966;71:807-12.

3. Butto F, Lucas RV, Edwards JE. Persistent trnncus arteriosus: patho- logic anatomy in 54 cases. Pediatr Cardiol 1986;7:95-101.

4. WolfAJ, Casta A, Nichols M. Anomalous origin and malposition of the pulmonary a~eries (crisscross pulmonary arteries) associated with complex congenital heart disease. Pediatr Cardiol 1986;6:287-91.

5. Congdon ED. Transformation of the aortic-arch system during the de- velopment to the human embryo. Carnegie Institute Contributions to Embryology 1922;14:47.

6. Wells TR, Takahashi M, Landing BH, Ritchie GW, Ang SM, Diaz JF, Mahnovski V. Branching patterns of right pulmonary artery in cardio- vascular anomalies. Pediatr Pathol 1993;13:218-23.

latrogenic coronary septal artery-to-right ventricular fistula complicating percutaneous transluminal coronary angioplasty with spontaneous resolution

Mona Youssef, MD, a Alan Schob, MD, b, c and Kenneth M. Kessler, MD b, c Miami, Fla., and Lexington, Ky.

Percutaneous t rans lumina l coronary angioplasty (PTCA) is a widely used interventional procedure with major risks including coronary artery closure, myocardial infarction, and death. 1, 2 Iatrogenic coronary ar tery-ventr icular fis- tula has rarely been reported. 3, 4 A coronary artery fistula is an abnormal communication through which coronary artery blood is shunted into a cardiac chamber or other vascular structure without first passing through the my- ocardial capillary bed. This is a report of an iatrogenic sep- tal artery-to-right ventr icular fistula that resolved spon- taneously.

A 61-year-old white man was admitted to the hospital 2

From the aUniversity of Kentucky Medical Center, bDivision of Cardiology, Department of Medicine, University of Miami School of Medicine and CCar- diology Section, Medical Service, Department of Veterans Affairs Medical Center. Reprint requests: Kenneth M. Kessler, MD, Cardiology Section (lllA), Veterans Affairs Medical Center, 1201 N.W. 16th St., Miami, FL 33125. Am Heart J 1997;133:260-2. 4/1/76912

Fig. 1. Left coronary angiogram before angioplasty (right anterior oblique view) shows stenoses in left anterior de- scending artery (large arrowhead) and first two septal branches (small arrowheads).

months after PTCA of a subtotally occluded right coronary artery for elective cardiac catheterization. The pat ient had exertional angina-equiva len t symptoms, and an exercise stress thal l ium test was significantly positive. On the day of admission, he had a brief episode of burn ing midback pain at rest similar to, but less severe than, his pre-PTCA pains. Clinical examinat ion was unremarkable and the electrocardiogram revealed sinus bradycardia and non- specific ST changes in the anterolateral leads.

Coronary arteriography revealed a 70% proximal eccen- tric stenosis of the left anterior descending artery (LAD) involving the origin of two large septal branches (Fig. 1). Directional coronary atherectomy with an EX6F Simpson coronary atherectomy catheter (Devices for Vascular In- tervention Inc., Temecula, Calif.) of the proximal LAD was followed by dilation with an Applied Cardiac Systems 3.5, 30 mm perfusion balloon. The first septal branch was crossed with a 0.010 ACS high-torque intermediate ap- proach guide wire and dilated with two inflations by the use of a Scimed Rally 2.0 mm balloon (Maple Grove, Minn.). The first inflation was at 8 a tm for 2 minutes, and the second was at 10 a tm for 2.5 minutes. The Rally bal- loon was then exchanged for a Scimed Express 2.5 balloon,

Volume 133, Number 2

American Heart Journal Youssef, Schob, and Kessler 261

Fig. 2. Left coronary angiogram after angioplasty (left anterior oblique view) shows left anterior descending and septal branches. At the distal end of the septal branch contrast has collected in the interventricular septum, with a puffofcontrast entering the right ventricle (arrowheads).

and a 2-minute inflation at 6 atm was performed. All dila- tions were done without difficulty. The proximal LAD di- lation resulted in <20% residual stenosis, Thrombolysis in Myocardial Infarction (TIMI) trial perfusion grade III flow, and a moderate-sized dissection that was not flow limiting. Dilation of the first septal branch resulted in a 20% resid- ual stenosis (from 95%) with TIMI III flow.

After the wire was removed from the septal branch, per- foration of the distal part of the septal branch was noted by the extravasation of contrast material from the first septal branch to the muscular septum and into the right ventricle (Fig. 2). Subsequent angiography revealed post- procedure compromise at the origin of the first diagonal branch, which was dilated to a 40% residual stenosis with good distal flow. The patient was hemodynamically stable throughout the procedure, experienced no chest pains, and was transferred to the cardiac care unit recei~ng intrave- nous nitroglycerin, heparin, aspirin, and calcium channel blockers. The shunt flow was believed to be small as deter- mined by angiography, and flow was not measured by oximetry. However, the size of the shunt was unknown; no

Fig. 3. Left coronary angiogram at follow-up (left anterior oblique view) shows resolution of septal dissection/perfo- ration.

murmur was present. Twenty-four hours later, coronary angiography showed no significant change. A third coro- nary angiogram done 4 days later showed complete reso- lution of the distal septal perforation (Fig. 3). The patient was discharged taking isosorbide dinitrate, amlodipine, and metoprolol.

Three months later the patient had an exercise stress thallium test for exertional angina. Mild anterior wall is- chemia was noted near the apex. Following the full Bruce protocol, the patient had 2 to 4 mm ST segment depression inferiorly at 2 minutes and 17 seconds. Subsequent coro- nary angiography showed a 90% concentric stenosis at the origin of the first septal branch that was successfully dilated with a 2.5 mm Scimed Express, with 10% residual stenosis. The LAD showed a 90% proximal eccentric discrete lesion, the stenting of which resulted in 0% resid- ual stenosis by use of a Johnson & Johnson Palmaz-Schatz stent 3.0/15 mm. The prior septal perforation was not ev- ident. The patient was treated with coumadin and dipy- ridamole for 1 month and with aspirin indefinitely.

Coronary artery perforation after PTCA has rarely been reported. Localized or nonlocalized coronary perforations occur infrequently (<1% of patients) after balloon angio-

February 1997 2 6 2 Youssef, Schob, and Kessler American Heart Journal

plastY or the use of newer devices. 5 Coronary artery per- forations have been reported with greater frequency after coronary angioplasty with new devices than after s tandard balloon angioplasty. 6 Coronary perforation with balloon angioplasty generally occurs when the coronary guide wire becomes subint imal and is advanced through the coronary artery into the pericardial space. Meng and Har lan 3 reported a case of intracardiac perforation related to false aneurysm rupture after PTCA. Iannone and Iannone 4 re- ported an iatrogenic LAD-left ventr icular fistula after PTCA with a negative submaximal stress test after 7 days. Septal ar tery-r ight ventr icular fistula, to our knowledge, has not been previously reported. The unique feature in this case is the documented angiographic evidence of com- plete and spontaneous resolution of the fistula after 5 days.

The na tu ra l history of congenital coronary artery fistu- las varies, with 10ng periods of stability in some patients and gradual progression of symptoms in others. The nat- ural history of acquired coronary artery fistulas had not been adequately studied. Some acquired coronary artery fistulas related to frequent endomyocardial biopsies in pa- t ients undergoing cardiac t ransp lan t have been demon- strated to regress or disappear. 7

The complication was noted only after removal of the wire, which apparent ly tamponaded the perforation. The wire appeared to have migrated distally during the long and involved procedure. Septal contraction could have progressively buried the wire more deeply with each sys- tole. A possible explanation for the spontaneous and rela- tively rapid resolution of the fistula in our case is its apparent hemodynamic insignificance and its location, as well as the discontinuation ofheparin. Location within the muscular septum favors compression and obliteration of the fistula during systole. No murmurs were appreciated in this patient, but usual ly fistulas to the right ventricle have a continuous m u r m u r rather than the diastolic com- ponent often heard with fistulas to the left ventricle.

Localized coronary artery perforations can be managed

with prolonged balloon inflations across the site of perfo- rat ion and with reversal of anticoagulation. The mortali ty rate of urgent coronary artery bypass grafting after PTCA is approximately 7%, and up to a 41% incidence of nonfa- tal myocardial infarction has been reported, s, 9 In this pa- t ient who was clinically stable with an iatrogenic fistula tha t was apparent ly hemodynamically insignificant, close observation and conservative medical management was successful.

REFERENCES

1. Cowley MJ, Dorros G, Kelsey SF, Raden MV, Detre KM. Acute coronary events associated with percutaneeus transluminal coronary angio- plasty. Am J Cardiol 1983;53:12C-16C.

2. Park DD, Laramee LA, Teirstein P, Ligon RW, Giorgi IV, Hartzler GO, et al. Major complications during PTCA: an analysis of 5413 cases [ab- stract]. J Am Coll Cardiol 1988;2:237A.

3. Meng RL, Harlan JS. Left anterior descending coronary artery-right ventricular fistula complicating percutaneous transluminal anglo- plasty. J Thorac Cardiovasc Surg 1985;90:387-90.

4. Iannone LA, Iannone DP. Iatrogenie left coronary artery fistula-to-left ventricle following PTCA: a previously unreported complication with nonsurgical management. Am Heart J 1990;120:1215-7.

5. Popma JJ, Leon MB, Topol EJ. Complications ofcoronaryintervention: diagnosis and management. In: Atlas of interventienal cardiology. Philadelphia: Saunders, 1994:175-98.

6. Popma JJ, Leon MB, Topel EJ. Directional coronary atherectemy. In: Atlas of interventional cardiology. Philadelphia: Saunders, 1994: 226.

7. Sandhu JS, Uretsky BF, Zerbe TR, Goldsmith AS, Reddy FS, Kromos RL, et al. Coronary artery fistula in the heart transplant patient: a po- tential complication of endomyocardial biopsy. Circulation 1989; 79:350-6.

8. Dorros G, Cowley MJ, Simpson J, Bentivolgio IG, Block PC, Bourassa M, et al. Percutaneous transluminal coronary angioplasty: report of complications from the National Heart, Lung and Blood Institute PTCA Registry. Circulation 1983;67:723-30.

9. Cowley MJ, Dorros G, Kelsey SF, Raden MV, Detre K]YI. Emergency coronary bypass surgery after coronary angioplasty. The National Heart, Lung and Blood Institute's Percutaneous Transluminal Coronary Angioplasty Registry experience. Am J Cardio11984;53:22C- 26C.