Page 18 - Journal of Structural Heart Disease Volume 4, Issue 5

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Original Scientific Article
Prior to the era of echocardiography, the right cor- onary artery was considered to be the major site of origin of the fistulae (40-60%), followed by the left anterior descending (30-60%) then circumflex and a combination thereof. However, currently, we believe more fistulae originate in the left anterior descend- ing artery. The right side of the heart (ventricle, pul- monary arteries, right atrium, coronary sinus, etc) is the major drainage (termination) site of most fistulae (90%) [4, 5].
Prior to 1990’s, surgical ligation was considered the treatment of choice with external ligation of the fistu- la preferred if possible. However, if the fistula is poste- riorly located behind the heart, internal closure of the termination site on cardiopulmonary bypass offered a safe alternative [6]. Recurrence rate after surgical closure is about 10% [7].
Since the report by Reidy et al. [8], percutaneous closure in the cardiac catheterization laboratory has become the most common option for management of large fistulae. To enable successful and safe closure, it is imperative to define the anatomy of the fistula by selective coronary angiography. Detachable bal- loons, coils, devices, and vascular plugs all have been used successfully to close coronary fistulae [9, 10].
The purpose of this paper is to discuss the man- agement decisions and details of transcatheter clo- sure techniques.
Management Decisions
As mentioned above, small fistulae in an asymp- tomatic patient need not be closed. However, if the fistula is large or if the patient is symptomatic, closure is recommended. The decision process in managing fistulae depends on: site of origin of the fistula (prox- imal vs distal) [11], size of the fistula, patient’s symp- toms, presence of any complication caused by the fistula (angina, heart failure, endocarditis, rupture, etc), age of the patient, the anatomy of the fistula and presence of other indications to undergo an invasive procedure. The current recommendations by the AHA/ACC guidelines [12] include for Class 1: patients with continuous murmur should undergo exact de- lineation of the origin and termination of the fistula by either echocardiography or CT/MRI; patients with large fistulae should undergo closure (surgical or per-
cutaneous) after delineation of the exact anatomy and finally, small-moderate fistulae with complica- tions (ischemia, arrhythmias or ventricular dysfunc- tion of unexplained etiology) should undergo clo- sure. Last but not least, the approach of elimination of the fistula (surgical vs. transcatheter) depends on the expertise of the physicians involved in the man- agement of the patient.
Proximal Fistulae
If small in size with no symptoms, observation is recommended and no medications. However, if the fistula is medium or large with or without symptoms, closure is recommended (surgical vs. transcatheter) followed by antiplatelets for at least one year.
Distal Fistulae
If small in size with no symptoms, observation is recommended with no medications. However, if me- dium in size with or without symptoms one has two options: closure followed by antiplatelets for one year or observation while receiving antiplatelets indefi- nitely. If the fistula is large with symptoms, closure is recommended, 6 hours post-closure, heparin should be started to keep PTT at 1.5 times normal while war- farin is started. Patients should be discharged home on Warfarin to keep INR around 2.5 for a period of 6-12 months [11]. Also, these patients should receive antiplatelets indefinitely. If the fistula is large with no symptoms, one has two options: either observation while receiving antiplatelets indefinitely or closure. If fistula is closed, one should treat as large fistula with symptoms.
Another important factor in the decision-making process is the size of the patient.
Fistulae in small patients
If small-moderate in size, they can be left alone until the patient is bigger. Spontaneous regression of fistulae has been reported [13], however, if the fistula is big and leading to cardiac symptoms, closure is rec- ommended. Elective closure of moderate-large sized fistulae that are not causing symptoms is reasonable and can be performed once the child is an appropri- ate weight (approximately >15 kg).
If fistula is associated with other cardiac lesions (most commonly tetralogy of Fallot, patent ductus ar-
Al-Qahtani A. et al.
Catheter Closure of Coronary Fistulae