Diagnosis of a Persistent Coronary Fistula after Ventricular Septal Defect Patch Closure

Craig H. Scott, MD, Victor A. Ferrari, MD, Suneet Mittat, MD, and Martin G. St. John Sutton, FRCP, Philadelphia, PenmyS, ania

Penetrating chest trattma can result in multiple clinical syndromes depending on the structures involved. Tam- ponade, valvular regurgitation, ventricular septal de- fect (VSD), conduction system abnormalities, and cot-

onary lacerations have been reported. ~a We report a case of right ventricular free wall laceration, VSD, and coronary artery fistula involving a septal perforator. (J Am Soc Echocardiogr 1997;10:5734.)

A 22-year-old healthy male sustained a knife wound with approximately 10 cm penetrat ion through the left fourth intercostal space and angled medially. Initial physical examination was consis- tent with left pneumothorax. The patient was taken to the operating room where a median s ternotomy and pericardiectomy were performed showing a

From the Cardiovascular Division, Hospital of the University of Pennsylvania. Reprint requests: Craig H. Scott, MD, Cardiovascular Division, Hospital of the University of Pennsylvania, 9 Gates 7Pavilion, 3400 Spruce St., Philadelplaia, PA 19104. Copyright © 1997 by the American Societ T of Echocardiography. 0894-7317/97 $5.00 +0 27/4/78913

self-sealed right ventricular free wall puncture me- dial to the left anterior descending coronary artery and minimal pericardiai clot. The laceration was oversewn, and the chest was closed. Postoperative electrocardiographic findings were consistent with an evolving septal infarction. On postoperative day 4, a loud V / V I pan-systolic murmur was no ted across the precordium. An echocardiogram showed an akinetic basal and mid-septal segment, with a 1 cm wide nonrestrictive ventricular septal defect in the muscular septum inferior to the membranous septum (Figure t ) . The right ventricle was dilated and hypocontracdle, consistent with acute volume and pressure overload. Cardiac catheterization

Figl~e 1 Basal septal parasternal short-axis echocardiographic image with and without color Doppler velocity imaging show a I cm wide nonrestrictive vennicular sepia1 defect in the muscular sepmm inferior to membranous septum.

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Journal of the American Society of Echocardiography 574 Scott et al. June 1997

Figure 2 Right anterior oblique cineangiogram showing the septal coronary arterial-cameral fistula, with contrast agent seen entering the left ventricular chamber through the VSD.

Figure 3 Small low-velocity diastolic jet within the VSD after the patch repair confirmed the continued presence of the septal coronary arterial-cameral fistula that drains into the left ventricle.

Journal of the American Society of Echocardiography Volume 10 Number 5 Scott et ai. 37S

showed a Qp /Q~ ratio of 2.1:1 and a septal coro- nary ar ter ia l -cameral fistula, with contrast agent seen enter ing the ventricular chamber (Figure 2). Surgical closure was delayed for 3 months until the infarction was comple ted and fibrosis had oc- curred. An intraoperative t ransesophageal echocar- d iogram (TEE) was performed. High flow in the VSD t h r o u g h o u t the cardiac cycle prevented detec- t ion o f the low-velocity flow of the coronary fistula. After the patch closure o f the VSD, however, the fistula flow became apparent.

The natural history of a coronary fistula is one of progressive dilatation that may result in a coronary steal phenomenon, angina, or congestNe heart failure without the presence of coronary stenosis, s Intramus- cular fistulas can be difficult to ligatc during VSD patch closure surgery because o f inadequate visual- ization, even with injections of methylene blue dye into the epicardial coronary artery. I t is possible to use the VSD repair to compress the artery enough to tamponade flow. Catheter-based embolization is an- other option 4 but has been generally used in congen- ital fistulas mad may result in infarction if the artery is occluded too proximally.

TEE with Doppler imaging is sensitive to low- velocity flow. Previous reports have shown flow within matured or congenital fistulas with the use o f TEE. s,6 This is the first report, to our lmowledge, o f flow visualization in a relatively new fistula without dilatation and the first description of visualization of the fistula flow after VSD patch closure. Postopera- tive VSD repair imaging is useful to evaluate the adequacy of the patch closure to avoid a residual

defect which could expand over time. In this case, it was also necessary to determine whether flow per- sisted in the septal coronary fistula. A small low- velocity, diastolic jet within the VSD after the patch repair confirmed the continued presence of the fistula (Figure 3). Lack o f a high-velocity continuous flow excluded residual VSD. In this patient, the TEE defined a clinical disorder that may become symp- tomatic as the fistula matures and identified a condi- tion that will require continued clinical monitoring.

We report a case o f traumatic VSD and septal coronary artery fistula where TEE was able to show the presence of the fistula and exclude residual VSD.

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