Correspondence

Fistula between the Left Internal Thoracic Artery and the Coronary Sinus

N Engl J Med 2000; 343:149-150July 13, 2000

Article

To the Editor:

Coronary cameral fistulas are communications between the coronary arterial circulation and the chambers or great vessels of the heart. The majority of these fistulas are congenital in origin. However, acquired coronary cameral fistulas are increasingly recognized as a complication of exogenous trauma (e.g., chest injury) or endogenous trauma (e.g., permanent ventricular pacing leads, cardiac surgery,1,2 or myocardial infarction). Acquired fistulas may also complicate the course of severe atherosclerosis.3 The symptoms are highly variable: the majority of patients have no symptoms, but others have chest pain and dyspnea.

We describe a 78-year-old man who had progressive angina, exertional dyspnea, and orthopnea. Six years previously, he had undergone coronary-artery bypass grafting (three saphenous-vein grafts and grafting of the left internal thoracic artery to the left anterior descending artery). A systolic–diastolic murmur was heard over the precordium. Coronary arteriography revealed opacification of the coronary sinus after injection into the left internal thoracic artery. The opacification was due to a fistula between the left internal thoracic artery and the coronary sinus (Figure 1Figure 1Coronary Angiograms from a Patient with a Fistula at an Internal-Thoracic-Artery Graft, with Drainage to the Coronary Sinus.). The anastomosis between the left internal thoracic artery and the left anterior descending artery was occluded. The patient had a second operation, with ligation of the fistula and reconnection of the left internal thoracic artery to the left anterior descending artery. Unfortunately, cardiogenic shock developed, and the patient died three days later.

This patient had been well for several years; symptoms developed only during the last few weeks before his death. We believe that the occlusion of the anastomosis between the left internal thoracic artery and the left anterior descending artery and the development of the fistula were two coincidental processes. We do not believe that the fistula was an immediate, inadvertent complication of the coronary-artery bypass grafting performed six years earlier. Instead, we believe it was a late complication of that procedure. Nonetheless, since many patients with fistulas do not have symptoms, it may have been a long-standing condition, with the occlusion of the anastomosis accounting for the onset of symptoms.

Vincent P.P.G. Renard, M.D.
Johan Vandenbogaerde, M.D., Ph.D.
Groeninghe Medical Center, B8500 Kortrijk, Belgium

3 References

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   Said SAM, van der Werf T. Acquired coronary cameral fistulas: are these collaterals losing their destination? Clin Cardiol 1999;22:297-302
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