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TRANSCATHETER CLOSURE OF DR DO NGUYEN TIN DAO ANH QUOC, MD CHILDREN HOSPITAL 1, HCMC... AIM • Describe the techniques used in transcatheter closure of coronary artery fistula.. • Report

TRANSCATHETER CLOSURE OF

DR DO NGUYEN TIN DAO ANH QUOC, MD CHILDREN HOSPITAL 1, HCMC

AIM

• Describe the techniques used in transcatheter closure of coronary artery fistula

• Report our results with this procedure

• Compare our findings with those described in the transcatheter and recent surgical

literature

INTRODUCTION

• Abnormal connection between one of the coronary arteries and a heart chamber or another blood vessel

• Rare anomalies 0.002% population, 0.4% cardiac malformations

• Congenital or acquired

• Continuous murmur

HISTORY

• The first described by Krause 1865

• Abbott: morphology of fistula 1906

• Bjork and Crafoord: surgical closure 1947

• Haller and Little: angiography for surgery 1963

• Reidy: successful percutaneous closure 1983

• Drainage

– PA 15% to 43% – RV 14% to 40% – RA 19% to 26% – LV 2% to 19% – LA 5% to 6%

RCA to LA

RCA to RV

RCA to LV

COMPLEX FISTULA

Single fistula

Multiple fistula

Simple Aneurysm

Complex Aneurysm

Natural History and Complications

• Spontaneous closure very uncommon

• Excessive load to cardiac chambers

• Coronary complications

• Valvular and endocardial complications

• Extracardiac complications

SHOULD WE CLOSE THE FISTULA?

HOW AND WHEN?

• Closure has been recommended because of its

complications

• Treatment by transcatheter or surgical closure

gives the best results

• Performe early in the course of the disease

Retrograde with plug

Retrograde with ADOI

Retrograde with VSD muscular

Retrograde with ADOII

Antegrade with plug

Antegrde with coils

Antegrade with coils in complex

RESULTS

• Immediate results

• Complete occlusion: 3 cases

• Residual shunt: 10 cases

• Non intervention : 2 cases

• Coronary branches appear again

• Balloon test for evidence of ischemia: we kept the device at least 30 minutes before release to check myocardial ischemia

• Short- term and long- term results

• Complete occlusion: 77% (10/13)

• Residual shunt : 15% (2/13)

• Shunt RV- aneurysm: 1 case

• Short- term and long- term results

• No major complication recorded

• No vascular injury

• No myocardial infarction

• Occlusion some small branches

• Arrhythmia: 1 case with VPC

• Heart failure: 1 case due to long term myocardial ischemia

DISCUSSION

• THE SITE to occlude the fistulous artery:

 As distally as possible or

 As close to its termination point as possible,

 Avoiding any possibility of occluding branches to the normal myocardium

• BUT, NO embolization beyond the fistula

• Occlusion is effected at a very precise point

• Antegrade or retrograde approach

 Advantages of retrograde approach

1 Bigger size of devices can be used

2 Avoid coronary damages

 Advantages of antegrade

1 Easier to reach the lesions

2 Choose the right position to occlude

CONSIDERATIONS IN PEDIATRIC

• Age of the patient

 Small vessels, small catheters but big fistula and big devices

 Small aorta: difficult to do coronary angiography

 Small amount of contrast

 The smaller heart size, the more tortouos fistula

CONCLUSION

1 Excellent results can be achieved by the transcatheter

embolization techniques to treat coronary artery fistulas

2 Difficult in technique: small vessels and tortouos

3 It is vital to select suitable device for the size and location

of the fistula

4 Nowadays, no patient should be referred for surgical

ligation unless transcatheter closure has been considered