A Case of Ischemic Angina with Heart Failure due to Congenital Coronary Aterial Anomaly

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1 : A Case of Ischemic Angina with Heart Failure due to Congenital Coronary Aterial Anomaly Kwang Won Ryu, M.D., Sin Bae Joo, M.D., Se ung Min Cho i, M.D., Yo ung Jin Joo, M.D., Young Jin Kim, M.D., Hong Sun Lee, M.D. Department of Internal Medicine, National Medical Cent er, Seoul, Korea Coronary artery fistula is an unusual anomaly in elderly patients that consists of a communication between one of the coronary arteries and other cardiac chambers or veins. It causes many cardiac complications due to hemodynamic changes, and thus has recognized its clinical significance. It occurs usually in congenital origin, but also occurs secondarily in traumatic or neoplastic or artherosclerotic coronary diseases. Congenital coronary artery fistula is a very rare congenital anomaly that results in multiple hemodynamic complications. It has reported rarely in elderly patients, that induces myocardial ischemia due to coronary steal syndrome and heart failure that caused by diastolic volume overload via a left to left shunt. We observed a 68-year-old male patient with exertional chest pain and dyspnea, in whom selective coronary angiography revealed abnormal reticular communication between left anterior descending artery and left circumflex artery and drained to left ventricle through multiple microfistulous channels. We report this patient case who complicated by myocardial ischemia and left ventricular failure those caused by hemodynamic complication due to multiple coronary artery-left ventricular fistulae. Key Words: Coronary artery fistula, Left to left shunt, Coronary steal syndrome, Myocardial ischemia, Left ventricular end-diastolic volume overload 1,2).,,., : , : : ~ noubunam@hanmail.net 3).,

2 Kwang Wo n Ryu, et al. A Case of Ischemic Angina due to Congenital Coronary Aterial Anomaly, III NYHA classification(new York Heart Association) III,,. 1,2,3). 10% ,6).. -,, (coronary steal syndrome) (left to left shunt) 7).,,. 68. (microfistulae) 203,000/mm 3,, -, BUN 13 g/dl mg/dl, AST/ALT 34/ 14I U/L,. : O, 68 : : 1994, ST T, 1 (Fig. 1A). X- 3 10,. CCSC(Canadian Cardiovascular Society Classification) : : -. : 40 pack-year :. : 130/70 mmhg, 107 /, 20, : CBC, 7000/mm g/dl 41.7% ph mmhg 97.6 mmhg 24.5 meq/l 97.7%, Cardiac troponin I <0.2 ng/ml(0 1), CK-MB 2.2 ng/ml(0 4.3), myoglobin 113 ng/ml(0 107), BNP 43.9 pg/ml( <100), HbsAg/Ab(-/-), CRP 19ng/dL,. X- : HRCT:

3 5. 1 Fig. 1. A, 12 Lead electrocardiogram at admission. It shows atrial fibrillation with rapid ventricular response and left ventricular hypertrophy by voltage criteria. B, Follow- up 12 lead electrocardiogram after medical treatment. It shows that previous cardiac arrhythmia is converted to normal sinus rhythm. CT,, 45%,., :. :

4 Kwang Wo n Ryu, et al. A Case of Ischemic Angina due to Congenital Coronary Aterial Anomaly Fig. 2. Selective left coronary angiogram at RAO caudal proection. Opacification of the left ventricular cavity through a network of microfistulae originating from the left LAD & left circumflex artery is visible. Fig. 3. Same as in figure 2 plane at the time of diastole.. 24 :. :,,.., (LV end-diastolic pressure = 21mmHg) (Fig. 2, 3). (Fig. Fig. 4. Selective right coronary angiogram at LAO projection. Normal coronary artery is seen. : 4), ( )

5 5. 1 Fig. 5. Follow- up selective left coronary angiogram at RAO cranial projection. It shows diminished contrast leakage to left ventricular cavity through a network of microfistulae(about 40~ 50%). Two ligated metal clips are visible at the first & second diagonal branch area(arrow). (amiodarone 200 mg qd PO), 40% (Fig. 5, 6),. (nitrate) 4 METs. (metabolic equivalent by modified Bruce protocol),,.. 20, Fig. 6. As compared with figure 1,2 at RAO caudal projection, markedly decreased contrast leakage from left coronary artery to left ventricular cavity is seen ,.. CCSC III CCSC II, 1-3)

6 Kwang Wo n Ryu, et al. A Case of Ischemic Angina due to Congenital Coronary Aterial Anomaly,, (left to left shunt) 4). 7). Nawa - 73, 55%, 35%, 51, 12, 5%, intertrabecular spaces sinusoids, 10 10). 1).,,,,,. 1,2) 1,2). 10% 5,6) %,,,,, -,,,, 3% 5,6)., ; 1-3). U. Stierle 7,262 aterial-luminal type 8, arterio-sinusoidal type -,, arterio-capillary type 9). Gradaus 8,9). Thallium 201. arterio-sinusoidal type. 2). (coronary - steal syndrome),, (coronary steal syndrome) 7,9)

7 5. 1, 14,20-22), 11)., - 10)., 7,12). 1,4,9,23).,,, 24,,,,. 13,15)..,,..,,.., 68 16),, 12,17,18)., (microfistulae),, -, 1,,. 9,19). : -,,,,,

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