https://orcid.org/0000-0002-8116-0887
A 49-year-old woman with New York Heart Association-World Health Organisation II dyspnoea was referred for multiples coronary fistulas. Cardiac tomography scan (CT-scan) and cardiac catheterization showed very tortuous coronary fistulas between the circumflex coronary artery and the right coronary artery towards the right atrium at its junction with coronary sinus (Supplementary material online). Mean pulmonary artery pressure was 21 mmHg with pulmonary to systemic output ratio at 1.6. The fistulas were very tortuous, and the usual way of closure by creating a arterio-venous loop was judged challenging. Therefore, cannulation of the fistulas from the right atrium was considered using fusion techniques.
During procedure, real-time fluroscopy was merged with the 3D model derived from CT-scan (HeartNavigator, Philipps, Netherland) and with real-time trans-oesophageal echocardiography (Echonavigator, Philips Healthcare, UK). These techniques showed a straight way from the superior vena cava to the largest connexion between fistulas in the right atrium (Panel). First tentatives to cross the fistulas by the arterial root failed despite the use of several guidewires and microcatheters (Supplementary material online). Fusion modalities were useful to target and enter the fistula exit into the right atrium via the jugular vein. This fistula was closed distally by 8 mm Amplatzer Vascular Plug type IV (Abbott, USA) using the over-guidewire technique (Supplementary material online). Angiogram before and after release demonstrated full occlusion of the circumflex fistula without distal coronary branches obstruction or any electrocardiogram modifications (Panel). In this challenging case, 3D reconstruction and multimodality fusion imaging improved procedure planification, trajectory choice, and real-time guidance of a complex percutaneous treatment for congenital heart diseases.
Supplementary material is available at European Heart Journal online.
Dr Adelaïde Richard (Intercard Lille France), Dr Alexandre Delarue, Docteur Said Bichali, Docteur Pierre-Alexandre Fontanges (Lille University Hospital. Lille France), and Mr. Xavier Ulysse (Philips, France).
All the authors certify that most relevant data are included in the article or the supplementary data. Moreover, authors commit to provide after a simple mail to the corresponding author all requested supplementary data as for example: the CT-scan images before 3D reconstruction, the diagnostic catheterization data, the stress test, etc. Obviously, data will be treated within the respect of the patient privacy and the ethical rules of the medical institutions.
Author notes
Conflict of interest: A.H. is a proctor for Occlutech (Occlutech, Sweden). I.B. is a consultant for Amplatzer (Abbott, USA). O.D. has no conflict of interest.
