Coronary artery fistula caused by an endocardial active fixation ICD lead

Tobias Härle, Jacobus Reimers, Anselm Schaumann
2008 Europace  
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
more » ... 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.
doi:10.1093/europace/eun034 pmid:18292123 fatcat:37exvmjicfhjpem6ny4d4b2onm