A 78 year old man with history of ventricular bigeminy and intermittent dyspnea on exertion presented with new onset palpitations. No symptoms of heart failure were elicited. Physical exam revealed an irregular rhythm and a soft crescendo decrescendo systolic ejection murmur at both upper sternal borders. Laboratory data were unremarkable. An electrocardiogram (ECG) initially showed supraventricular tachycardia. Loading with amiodarone changed the rhythm to a rate controlled atrial flutter with variable atrioventricular block. A trans esophageal echocardiogram (TEE) and elective cardioversion were done with conversion to sinus rhythm. Incidentally, the TEE documented significant diastolic flow, suggestive of a large coronary fistula. A cardiac computerized tomography (CT) with coronary CT angiography revealed a large (4 cm), tortuous and aneurysmal right coronary artery fistula communicating with the superior vena cava (SVC), confirmed by coronary angiography. An 8 x 15 mm ostium secundum atrial septal defect (ASD) was also noted. Surgical correction was accomplished with complete recovery. On the 2‐month follow up, patient remained asymptomatic.
Coronary artery fistulas (CAF) are rare cardiac anomalies, shunting blood from the coronaries into a cardiac chamber or a great vessel, their incidence being only 0.002%. Bypassing the myocardium, they can cause ischemia, infarction or hemodynamically significant shunt. They arise commonly from the right coronary artery or left anterior descending artery, and drain directly into the ventricles or rarely the SVC. Congenital or acquired, most patients remain asymptomatic, however those with symptoms usually present in the fifth or sixth decade of life. Clinical presentations include fatigue, dyspnea, angina, stroke, a continuous heart murmur. ECG and Chest X‐ray may show abnormalities indicating right ventricular volume overload. Though new imaging modalities like contrast enhanced CT/ Magnetic Resonance Imaging (MRI) may aid in diagnosis, coronary angiography remains gold standard.
Coronary fistulas may be complicated by myocardial ischemia (coronary steal syndrome) / infarction, pulmonary arterial hypertension or congestive heart failure. Other rare complications include arrhythmias, infectious endocarditis, rupture with cardiac tamponade or sudden death. Management of these lesions continues to be a matter of debate due to their rarity. Some authors would even consider treatment of asymptomatic patients, considering the evolutive nature and potentially foreseeable complications of the lesions. However, by and large, symptoms, complications and significant shunts contribute as major indications for surgical closure.
Though atrial flutter may be an under‐recognized and rare presenting feature of CAFs, this case illustrates the importance of early recognition and surgical intervention of anomalies, if indicated, in preventing further potential complications.
To cite this abstract:Basit A, Chandra K, Wang B, Sanchez‐Torres R. An Odd ‘Path’ to Atrial Flutter. Abstract published at Hospital Medicine 2014, March 24-27, Las Vegas, Nev. Abstract 342. Journal of Hospital Medicine. 2014; 9 (suppl 2). https://www.shmabstracts.com/abstract/an-odd-path-to-atrial-flutter/. Accessed March 31, 2020.