Coronary artery fistula caused by an endocardial active fixation ICD lead
A 63-year-old man with a history of chronic heart failure due to non-ischaemic cardiomyopathy presented with dyspnoea, peripheral oedema, chest pain, and a new systolic heart murmur. A pacemaker had been implanted 18 years ago because of a symptomatic sick sinus syndrome. Surgical mitral valve reconstruction was done 3 years ago for progressive mitral regurgitation. At that time coronary angiography had shown no pathological findings. One year later, a biventricular implantable
... le cardioverterdefibrillator (ICD) had been implanted for primary prevention of sudden cardiac death and device therapy in heart failure because of reduced left ventricular function (ejection fraction 0.26%) and left bundle branch block with dyssynchrony. Coronary angiography during the current admission revealed a large coronary artery fistula from the left anterior descending artery to the right ventricle ( Figure 1) . The fistula was adjacent to the tip of the screw-in endocardial ICD lead, which penetrated into a small septal vessel. Therefore, formation of the coronary artery fistula has to be stated as a complication of the ICD lead placement. In order to quantify the shunt, right-heart catheterization with an oximetry run was performed, revealing a small left-to-right shunt of 0.29 L/min (8%; Q P /Q S ¼ 1.1). Pulmonary artery and right-heart pressures were within the normal range. There were no signs of perforation, and pericardial effusion was excluded. A check of the ICD demonstrated appropriate function with stable values for sensing, pacing threshold, and impedance. Due to the small shunt volume, a conservative therapy approach was chosen, and symptoms of heart failure were regressive under optimized medical therapy. Figure 1 Coronary artery fistula originating from a septal branch of the left anterior descending artery and draining into the right ventricle secondary to implantation of a screw-in endocardial ICD lead. (A) Left lateral view. (B) Left anterior oblique view.