Koroner Anevrizma ve Koroner Fistüllü Olguya Yaklaşım
Özet
Akut koroner sendrom (AKS) tablosuyla başvuran 55 yaşında bir erkek hastada saptanan nadir bir koroner arter fistülü (KAF) olgusu sunulmaktadır. Göğüs ağrısı şikayetiyle acile başvuran ve ST yükselmesiz miyokart enfarktüsü (NONSTEMI) tanısı alan hastanın yapılan koroner anjiyografisinde, sol anterior desendan arterden (LAD) köken alıp sol ventriküle drene olan geniş, kıvrımlı ve büyük çaplı bir fistül tespit edilmiştir. Koroner arter fistülleri genellikle konjenital kaynaklı anomaliler olup, ektazik bölgelerdeki akım durgunluğu nedeniyle tromboz ve enfarktüs riski taşıyabilir. Klinik olarak semptomatik ve hemodinamik açıdan anlamlı olan KAF vakalarında perkütan veya cerrahi kapatma yöntemleri önerilmektedir. Olgumuzdaki hastaya Kalp Damar Cerrahisi tarafından cerrahi müdahale önerilmiş ancak hastanın tedaviyi kabul etmemesi üzerine aspirin, metoprolol ve trimetazidin içeren medikal tedavi protokolü düzenlenerek taburculuğu sağlanmıştır. Genellikle asemptomatik seyreden ve rastlantısal olarak saptanan bu tür anomalilerin, morbidite ve mortalite riski nedeniyle doğru teşhis ve takibi kritik öneme sahiptir.
A rare case of a coronary artery fistula (CAF) is presented in a 55-year-old male patient who presented with acute coronary syndrome (ACS). The patient was admitted to the emergency department with chest pain and diagnosed with non-ST-elevation myocardial infarction (NONSTEMI). Coronary angiography revealed a large, tortuous, and dilated fistula originating from the left anterior descending artery (LAD) and draining into the left ventricle. Coronary artery fistulas are mostly congenital anomalies, and sluggish blood flow within ectatic segments can predispose patients to thrombosis and subsequent infarction. For clinically symptomatic and hemodynamically significant CAF cases, either percutaneous or surgical closure is indicated. Although cardiovascular surgery was recommended for the patient in this case, he declined the surgical intervention; consequently, he was discharged with a medical regimen consisting of aspirin, metoprolol, and trimetazidin. Since CAFs are usually asymptomatic and incidentally diagnosed, accurate identification and management remain crucial due to potential morbidity and mortality risks.
Referanslar
Gillebert C, Van Hoof R, Van de Werf F, Piessens J, De Geest H. Coronary artery fistulas in an adultpopulation. EurHeart J 7: 437-443,1986.
Urasawa K, Inoue N, Yokota T,et al. Mural thrombus in an ectatic right coronary artery caused acute myocardial infarction at down stream coronary artery. IntHeart J 46: 313-316,2005.
Baltaxe HA, Wixson D. The incidence of congenital anomalies of the coronary arteries in the adult population. Radiology 1977;122:47-52.
Vaidya YP, Green GR. Coronary artery fistula. J CardSurg. 2019;34: 1608-1616.
Shriki JE, Shinbane JS, Rashid MA, et al. Identifying,characterizing and classifying congenital anomalies of the coronary arteries. Radiographics 2012;32: 453-68.
Yamanaka O, Robert E. Hobbs. Coronary artery anomalies in 126,595 patients under going coronary arteriography. Cathet Cardiovasc Diagn 1990;21:28-40.
Unzue´ L, Garcı´a E, Dı´az-Anto´n B, Ferna´ndez-Portales J, Teijeiro R, Rodrı´guez-del Rı´o M. Percutaneous closure of a giant coronary artery fistula after surgical pericardiectomy. Review of theliterature. Cardiovasc Revasc Med 2017;18:384–389.
Yun G, Nam TH, Chun EJ. Coronary artery fistulas: pathophysiology, imaging findings, and management. RadioGraphics 2018;38:688–703.
Stout KK, Daniels CJ, Aboulhosn JA, Bozkurt B, Broberg CS, Colman JM et al. 2018 AHA/ACC guideline for the management of adults with congenital heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation 2019;139:e698–e800.
Kimura M, Shiraishi J, Ito D, Ariyoshi M, Matsui A, Arhara M, et al. Usefulness and limitation of transthoracic echocardiography in the diagnosis of large coronary artery fistula. Echocardiography 2010;27:1291–1295.
Pursnani A, Jacobs JE, Saremi F, Levisman J, Makaryus AN, Capunay C et al. Coronary CTA assessment of coronary anomalies. Cardiovasc Comput Tomogr 2012;6:48–59.
Lee SK, Jung JI, O JH, Kim HW, Youn HJ. Coronary-to-pulmonary artery fistula in adults: evaluation with thallium-201 myocardial perfusion SPECT. PLoSOne 2017; 12:e0189269.
Sommer RJ, Hijazi ZM, Rhodes JF. Pathophysiology of congenital heart disease in theadult. Circulation 2008;117:1090–1099.
Jama A, Barsoum M, Bjarnason H, Holmes DR Jr, Rihal CS. Percutaneous closure of congenital coronary artery fistulae: results and angiographic follow-up. JACC Cardiovasc Interv 2011;4:814–821.
