Transcatheter Occlusion of a Giant Coronary Artery Fistula in a Neonate

Abstract

BACKGROUND Although large coronary artery fistulas are uncommon; they lead to substantial over-circulation in the pulmonary vascular beds and left heart system. Fistula occlusions are achieved via surgical or transcatheter technique; however, reports on successful outcomes of transcatheter treatment during the neonatal period are limited. CASE REPORT A female infant was born at the gestational age of 37 weeks with a birth weight of 2615 grams via normal vaginal delivery. Cardiac auscultation revealed a loud continuous murmur emanating from the fourth right intercostal space. A right coronary artery-to-right ventricle fistula was confirmed using transthoracic echocardiography. The newborn developed respiratory distress 3 days after birth and was administered continuous positive airway pressure to assist breathing. On day 8, the ventilator was used through tracheal intubation due to gradual worsening of dyspnea. A 6-mm Amplatzer Vascular Plug 4 (AGA Medical Corporation, Plymouth, MN) was chosen, as the minimum diameter of the coronary artery fistula was 5 mm. In view of the risk of myocardial ischemia with additional devices, the procedure was stopped despite persistent shunting. The newborn's clinical condition significantly improved following the procedure and she was eventually weaned off ventilator support. CONCLUSIONS A self-expanding occlusion device was useful for relieving this life-threatening condition. Complete elimination of shunting is not always necessary, to avoid compromising myocardial circulation.

Figure 1.

Transthoracic echocardiograms. (A, B) Parasternal short-axis views. (C, D) Subxiphoid views. Arrows: Proximal right coronary artery markedly dilated. Ao – aorta. (Adobe Photoshop Elements 18.0).

Figure 2.

Electrocardiogram. There were no abnormal Q waves or ST-T changes in leads II, III, and aVF. (Adobe Photoshop Elements 18.0).

Figure 3.

Right coronary angiography. Pre-procedure: Frontal (A) and lateral projections (B); Proximal right coronary artery (white arrows) was markedly dilated. The “neck” of the fistula (red arrows) was defined proximal to it, entering the right ventricle (RV). Post-device deployment: Frontal (C) and lateral projections (D); A self-expandable device (yellow arrows) was deployed at the neck of the fistula. (Adobe Photoshop Elements 18.0).