Devamlı Üfürümün Nadir Bir Nedeni: Koroner Arteriyel Fistüller
Özet
Koroner arteriyel fistüller (KAF), koroner arterler ile kalp boşlukları veya major damarlar arasında gelişen ve popülasyonda %0.002 oranında nadir görülen konjenital anomalilerdir. Özgün bir semptomu olmaması nedeniyle sıklıkla gözden kaçabilen bu hastalıkta, fizik muayene ve görüntüleme teknikleri tanıda hayati öneme sahiptir. Bu vaka takdiminde, 5-6 aydır efor dispnesi şikayeti olan, hipertansiyon hastası 63 yaşında bir kadın hasta sunulmaktadır. Yapılan kardiyak oskültasyonda, sol sternal kenar boyunca diyastolik fazda belirginleşen 3/6 şiddetinde devamlı bir üfürüm saptandı. Transtorasik ekokardiyografide (TTE) sağ kalp boşluklarında dilatasyon, sistolik pulmoner arter basıncında artış (45 mmHg), orta triküspid yetmezliği, anevrizmatik sağ koroner arter (RCA) ostiumu (10 mm) ve dilate koroner sinüs (CS) izlendi. M-mod renkli doppler incelemesinde türbülan akımın mid ve geç diyastolde arttığı saptanırken, Qp/Qs oranı 2,5 olarak ciddi şantı ortaya koydu. Üç boyutlu anatomiyi değerlendirmek amacıyla yapılan koroner BT anjiyografide, RCA'nın anevrizmatik ve tortiyoz seyrettiği, kalbin tabanında CS ile birden fazla fistül oluşturduğu belirlendi. Semptomatik seyri ve ciddi şantı nedeniyle konsey tarafından cerrahi kapatma önerilen hasta, operasyonu kabul etmeyerek medikal tedaviyle takibe alınmıştır.
Coronary arterial fistulas (CAF) are rare congenital anomalies developing between coronary arteries and cardiac chambers or major vessels, with a general population prevalence of 0.002%. Often overlooked due to the lack of specific symptoms, physical examination and advanced imaging methods hold critical importance for diagnosis. This case report presents a 63-year-old female patient with hypertension complaining of exertional dyspnea for 5-6 months. Cardiac auscultation revealed a 3/6 grade continuous murmur along the left sternal border, which became more prominent during the diastolic phase. Transthoracic echocardiography (TTE) demonstrated dilated right cardiac chambers, elevated systolic pulmonary artery pressure (45 mmHg), moderate tricuspid regurgitation, an aneurysmal right coronary artery (RCA) ostium (10 mm), and a significantly dilated coronary sinus (CS). Color Doppler M-mode imaging confirmed that turbulent flow intensified during mid-to-late diastole, and a Qp/Qs ratio of 2.5 indicated a hemodynamically severe shunt. Coronary CT angiography, performed to evaluate the three-dimensional anatomy, identified an aneurysmal and tortuous RCA forming multiple fistulas with the CS at the cardiac base. Although surgical closure was recommended by the medical council due to severe shunting, the patient declined surgery and is currently managed with medical therapy.
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