Accepted Manuscript Multiple Coronary Arteries to Left Atrial Fistulae: An Uncommon Complication of Radiofrequency Ablation for Atrial Fibrillation Ji-Yong Jang, MD, Chi Young Shim, MD, PhD, Hui-Nam Pak, MD, PhD PII:
S0828-282X(15)00245-7
DOI:
10.1016/j.cjca.2015.03.027
Reference:
CJCA 1639
To appear in:
Canadian Journal of Cardiology
Received Date: 25 January 2015 Revised Date:
25 March 2015
Accepted Date: 25 March 2015
Please cite this article as: Jang J-Y, Shim CY, Pak H-N, Multiple Coronary Arteries to Left Atrial Fistulae: An Uncommon Complication of Radiofrequency Ablation for Atrial Fibrillation, Canadian Journal of Cardiology (2015), doi: 10.1016/j.cjca.2015.03.027. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT 1
Multiple Coronary Arteries to Left Atrial Fistulae: An Uncommon Complication of
2
Radiofrequency Ablation for Atrial Fibrillation
3
Ji-Yong Jang, MD; Chi Young Shim, MD, PhD; Hui-Nam Pak, MD, PhD
5
Cardiology Division, Severance Cardiovascular Hospital, Yonsei University College of
6
Medicine, Seoul, Republic of Korea
7
Short title: Multiple Coronary Arteries to Left Atrial Fistulae
8
Corresponding author:
9
Chi Young Shim, MD, PhD
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Cardiology Division, Severance Cardiovascular Hospital, Yonsei University College of
11
Medicine
12
50 Yonsei-ro, Seodaemun-gu, Seoul, Republic of Korea 120-752
13
Phone: +82-2-2228-8453, Fax: +82-2-227-7742
14
E-mail: [email protected]
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Word count: 999
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Number of Figures: 2
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Number of References: 5 1
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Brief summary
A 64 year-old man who had undergone catheter radiofrequency ablation three times in the
3
previous 3 years due to recurrent symptomatic atrial fibrillation revealed multiple coronary
4
fistulae to the left atrium on multimodality imaging. This case shows that the multiple
5
radiofrequency ablation procedure induced coronary neovascularization and fistulae
6
formation after ischemic injuries to the left atrium.
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Abstract A 64 year-old man had undergone catheter radiofrequency ablation (RFA) three times
3
in the previous 3 years due to recurrent symptomatic atrial fibrillation (AF). Five months
4
after the third RFA, unusually colored Doppler flows that drained into the left atrium (LA)
5
were newly identified. Coronary computed tomographic angiography indicated the presence
6
of multiple small fistulae reaching from the right and left circumflex coronary artery to the
7
LA, and this was confirmed using coronary angiography. This case shows that the multiple
8
RFA procedure induced coronary neovascularization and fistulae formation after ischemic
9
injuries to the LA.
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Keyword: Fistula, atrial fibrillation, radio frequency ablation
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Case report
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A 64 year-old man had undergone catheter radiofrequency ablation (RFA) three times
15
in 3 years due to recurrent symptomatic atrial fibrillation (AF), even when on antiarrhythmic
16
drug therapy. Before the first RFA procedure, there was no evidence of structural heart
17
disease or coronary artery disease on the patient’s echocardiogram or coronary computerized
18
tomographic (CT) angiogram (Fig. 1A). He underwent catheter RFA using an irrigated-tip
19
RFA catheter (Navistar Thermocool, Biosense Webster; 35 W, 15 mL/min irrigation for
20
anterior aspect and 25–30 W, 10 mL/min for posterior aspect) and a 3D electro-anatomical
21
map (Fig. 1B, 1C). Despite repeated RFA, atrial tachyarrhythmia recurred. Given the clinical
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ACCEPTED MANUSCRIPT 1
2
situation, we planned to implant an LA-appendage closing device. During the pre-procedural echocardiographic examination, unusually colored flows that drained into the left atrium (LA) were identified along the LA posterior wall (Fig. 1D, 1E;
4
Video 1). A continuous wave Doppler examination of the abnormal flow revealed a maximum
5
gradient of 27 mmHg (Fig. 1F). CT angiography revealed multiple small fistulae from the
6
right and left circumflex coronary artery to the LA (Fig 2A, 2B, 2C), which had not been
7
found on the previous CT angiogram (Fig 1A). Ultimately, coronary angiography confirmed
8
multiple small fistulae from the right and left circumflex coronary artery to the LA (Fig 2D,
9
2E; Video 2, 3). The patient received the LA appendage device closure as planned, and no
10
further RFA has been performed. He has had no fistulae-related signs or symptoms, and is
11
seen regularly at an outpatient clinic.
13
Discussion
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Coronary artery fistulae are uncommon vascular communications between the
15
coronary arteries and other cardiac structures; they can be congenital or acquired. Acquired
16
coronary artery fistulae can occur as a result of inflammation, atherosclerosis, trauma, or
17
collagen vascular disease.1 To the best of our knowledge, this is the first report of multiple
18
acquired fistulae as a complication of multiple RFA for AF, although one recent report
19
described an unusual fistula formation between the left circumflex artery and the LA cavity
20
secondary to mitral isthmus catheter ablation.2 The RFA posterior inferior aspect of the left
21
inferior pulmonary vein or the linear ablation connecting the lower margin of both inferior
22
veins (posterior inferior line) in the present case may have resulted in this collateral damage.
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ACCEPTED MANUSCRIPT RFA can cause heat damage on adipose tissue around the LA and the small branch of
2
coronary arteries that supply the adipose tissue.3 It can also induce ischemia of adipose tissue
3
and increase the free fatty acid level from apoptosis of the adipose cells. Additionally, RFA
4
triggers a cellular and molecular inflammatory cascade that has positive feedback loops
5
involving the vascular endothelial growth factor (VEGF).5 As there is no fibrous fascia layer
6
to impede the diffusion of a chemical agent in the coronary artery, epicardial fat, or the
7
myocardium, up-regulated VEFG may result in increased adipose-tissue vascularity and
8
enhanced formation of multiple small vasculature. Repeated RFA on the LA with increased
9
collateral flow from coronary arteries might thus create fistula tracks into the LA cavity. Thus,
10
multimodality imaging before repeated RFA could be helpful for detecting coronary collateral
11
flows to the LA. If neovascularization is strongly suspected, relatively low power and
12
temperature settings should be used in the application of RF energy along the posterior LA
13
wall to minimize the risk of developing this complication.
TE D
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SC
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1
Most coronary fistulae are detected incidentally. Closure of large fistulae has been
15
achieved most often with coils, though vascular plugs or covered stents can be used.
16
Intervention is recommended for all symptomatic coronary fistulae; however, only large,
17
audible fistulae should be occluded if there are no symptoms.
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Disclosures
20
None.
21
5
ACCEPTED MANUSCRIPT 1
References 1. Early SA, Meany TB, Fenlon HM, Hurley J. Coronary artery fistula; coronary
3
computed topography--the diagnostic modality of choice. J Cardiothorac Surg. 2008;
4
3:41.
SC
153:907-17.
M AN U
8
3. Sacks HS, Fain JN. Human epicardial adipose tissue: a review. Am Heart J 2007;
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caused by mitral isthmus ablation. Heart Lung Circ. 2014; 23:689-92.
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2. Hsieh CH, O’Connor S, Ross DL. Circumflex coronary artery to left atrium fistula
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RI PT
2
6
ACCEPTED MANUSCRIPT Figure Legends Figure 1. (A) Coronary CT angiography before the first RFA shows a normal circumflex artery. (B) (C) 3D electroanatomical maps with endocardial voltage. (D) (E) Transthoracic
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and transesophageal echocardiography show unusual turbulence flows along the LA posterior wall. (F) Continuous wave Doppler on the shunt flow shows continuous flow.
Figure 2. (A) Coronary CT angiography 5 months after the third RFA shows multiple small
SC
fistulae from the left circumflex coronary artery to the LA (white arrows) and (B) from the
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right coronary artery to the LA (white arrows). (C) 3D-reconstructed image of coronary CT angiography shows small arteries oriented from both the right and left circumflex coronary arteries covering the LA. (D) (E) Left and right coronary angiography shows multiple small fistulae from the coronary artery (short black arrows); contrast dye is drained into the LA
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Video legends
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(long black arrows).
Video 1. Transesophageal echocardiography shows unusual turbulence flows along the LA
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posterior wall.
Video 2. Left coronary angiography shows contrast dye filling into the LA through small coronary fistulae from the left circumflex artery. Video 3. Right coronary angiography shows contrast dye filling into the LA through small coronary fistulae from the right coronary artery.
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ACCEPTED MANUSCRIPT
S0828-282X(15)00245-7
DOI:
10.1016/j.cjca.2015.03.027
Reference:
CJCA 1639
To appear in:
Canadian Journal of Cardiology
Received Date: 25 January 2015 Revised Date:
25 March 2015
Accepted Date: 25 March 2015
Please cite this article as: Jang J-Y, Shim CY, Pak H-N, Multiple Coronary Arteries to Left Atrial Fistulae: An Uncommon Complication of Radiofrequency Ablation for Atrial Fibrillation, Canadian Journal of Cardiology (2015), doi: 10.1016/j.cjca.2015.03.027. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT 1
Multiple Coronary Arteries to Left Atrial Fistulae: An Uncommon Complication of
2
Radiofrequency Ablation for Atrial Fibrillation
3
Ji-Yong Jang, MD; Chi Young Shim, MD, PhD; Hui-Nam Pak, MD, PhD
5
Cardiology Division, Severance Cardiovascular Hospital, Yonsei University College of
6
Medicine, Seoul, Republic of Korea
7
Short title: Multiple Coronary Arteries to Left Atrial Fistulae
8
Corresponding author:
9
Chi Young Shim, MD, PhD
M AN U
SC
RI PT
4
Cardiology Division, Severance Cardiovascular Hospital, Yonsei University College of
11
Medicine
12
50 Yonsei-ro, Seodaemun-gu, Seoul, Republic of Korea 120-752
13
Phone: +82-2-2228-8453, Fax: +82-2-227-7742
14
E-mail: [email protected]
EP
AC C
15
TE D
10
16
Word count: 999
17
Number of Figures: 2
18
Number of References: 5 1
ACCEPTED MANUSCRIPT 1
Brief summary
A 64 year-old man who had undergone catheter radiofrequency ablation three times in the
3
previous 3 years due to recurrent symptomatic atrial fibrillation revealed multiple coronary
4
fistulae to the left atrium on multimodality imaging. This case shows that the multiple
5
radiofrequency ablation procedure induced coronary neovascularization and fistulae
6
formation after ischemic injuries to the left atrium.
AC C
EP
TE D
M AN U
SC
7
RI PT
2
2
ACCEPTED MANUSCRIPT 1
Abstract A 64 year-old man had undergone catheter radiofrequency ablation (RFA) three times
3
in the previous 3 years due to recurrent symptomatic atrial fibrillation (AF). Five months
4
after the third RFA, unusually colored Doppler flows that drained into the left atrium (LA)
5
were newly identified. Coronary computed tomographic angiography indicated the presence
6
of multiple small fistulae reaching from the right and left circumflex coronary artery to the
7
LA, and this was confirmed using coronary angiography. This case shows that the multiple
8
RFA procedure induced coronary neovascularization and fistulae formation after ischemic
9
injuries to the LA.
M AN U
SC
RI PT
2
10
11
Keyword: Fistula, atrial fibrillation, radio frequency ablation
13
Case report
TE D
12
A 64 year-old man had undergone catheter radiofrequency ablation (RFA) three times
15
in 3 years due to recurrent symptomatic atrial fibrillation (AF), even when on antiarrhythmic
16
drug therapy. Before the first RFA procedure, there was no evidence of structural heart
17
disease or coronary artery disease on the patient’s echocardiogram or coronary computerized
18
tomographic (CT) angiogram (Fig. 1A). He underwent catheter RFA using an irrigated-tip
19
RFA catheter (Navistar Thermocool, Biosense Webster; 35 W, 15 mL/min irrigation for
20
anterior aspect and 25–30 W, 10 mL/min for posterior aspect) and a 3D electro-anatomical
21
map (Fig. 1B, 1C). Despite repeated RFA, atrial tachyarrhythmia recurred. Given the clinical
AC C
EP
14
3
ACCEPTED MANUSCRIPT 1
2
situation, we planned to implant an LA-appendage closing device. During the pre-procedural echocardiographic examination, unusually colored flows that drained into the left atrium (LA) were identified along the LA posterior wall (Fig. 1D, 1E;
4
Video 1). A continuous wave Doppler examination of the abnormal flow revealed a maximum
5
gradient of 27 mmHg (Fig. 1F). CT angiography revealed multiple small fistulae from the
6
right and left circumflex coronary artery to the LA (Fig 2A, 2B, 2C), which had not been
7
found on the previous CT angiogram (Fig 1A). Ultimately, coronary angiography confirmed
8
multiple small fistulae from the right and left circumflex coronary artery to the LA (Fig 2D,
9
2E; Video 2, 3). The patient received the LA appendage device closure as planned, and no
10
further RFA has been performed. He has had no fistulae-related signs or symptoms, and is
11
seen regularly at an outpatient clinic.
13
Discussion
TE D
12
M AN U
SC
RI PT
3
Coronary artery fistulae are uncommon vascular communications between the
15
coronary arteries and other cardiac structures; they can be congenital or acquired. Acquired
16
coronary artery fistulae can occur as a result of inflammation, atherosclerosis, trauma, or
17
collagen vascular disease.1 To the best of our knowledge, this is the first report of multiple
18
acquired fistulae as a complication of multiple RFA for AF, although one recent report
19
described an unusual fistula formation between the left circumflex artery and the LA cavity
20
secondary to mitral isthmus catheter ablation.2 The RFA posterior inferior aspect of the left
21
inferior pulmonary vein or the linear ablation connecting the lower margin of both inferior
22
veins (posterior inferior line) in the present case may have resulted in this collateral damage.
AC C
EP
14
4
ACCEPTED MANUSCRIPT RFA can cause heat damage on adipose tissue around the LA and the small branch of
2
coronary arteries that supply the adipose tissue.3 It can also induce ischemia of adipose tissue
3
and increase the free fatty acid level from apoptosis of the adipose cells. Additionally, RFA
4
triggers a cellular and molecular inflammatory cascade that has positive feedback loops
5
involving the vascular endothelial growth factor (VEGF).5 As there is no fibrous fascia layer
6
to impede the diffusion of a chemical agent in the coronary artery, epicardial fat, or the
7
myocardium, up-regulated VEFG may result in increased adipose-tissue vascularity and
8
enhanced formation of multiple small vasculature. Repeated RFA on the LA with increased
9
collateral flow from coronary arteries might thus create fistula tracks into the LA cavity. Thus,
10
multimodality imaging before repeated RFA could be helpful for detecting coronary collateral
11
flows to the LA. If neovascularization is strongly suspected, relatively low power and
12
temperature settings should be used in the application of RF energy along the posterior LA
13
wall to minimize the risk of developing this complication.
TE D
M AN U
SC
RI PT
1
Most coronary fistulae are detected incidentally. Closure of large fistulae has been
15
achieved most often with coils, though vascular plugs or covered stents can be used.
16
Intervention is recommended for all symptomatic coronary fistulae; however, only large,
17
audible fistulae should be occluded if there are no symptoms.
AC C
18
EP
14
19
Disclosures
20
None.
21
5
ACCEPTED MANUSCRIPT 1
References 1. Early SA, Meany TB, Fenlon HM, Hurley J. Coronary artery fistula; coronary
3
computed topography--the diagnostic modality of choice. J Cardiothorac Surg. 2008;
4
3:41.
SC
153:907-17.
M AN U
8
3. Sacks HS, Fain JN. Human epicardial adipose tissue: a review. Am Heart J 2007;
TE D
7
caused by mitral isthmus ablation. Heart Lung Circ. 2014; 23:689-92.
EP
6
2. Hsieh CH, O’Connor S, Ross DL. Circumflex coronary artery to left atrium fistula
AC C
5
RI PT
2
6
ACCEPTED MANUSCRIPT Figure Legends Figure 1. (A) Coronary CT angiography before the first RFA shows a normal circumflex artery. (B) (C) 3D electroanatomical maps with endocardial voltage. (D) (E) Transthoracic
RI PT
and transesophageal echocardiography show unusual turbulence flows along the LA posterior wall. (F) Continuous wave Doppler on the shunt flow shows continuous flow.
Figure 2. (A) Coronary CT angiography 5 months after the third RFA shows multiple small
SC
fistulae from the left circumflex coronary artery to the LA (white arrows) and (B) from the
M AN U
right coronary artery to the LA (white arrows). (C) 3D-reconstructed image of coronary CT angiography shows small arteries oriented from both the right and left circumflex coronary arteries covering the LA. (D) (E) Left and right coronary angiography shows multiple small fistulae from the coronary artery (short black arrows); contrast dye is drained into the LA
EP
Video legends
TE D
(long black arrows).
Video 1. Transesophageal echocardiography shows unusual turbulence flows along the LA
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posterior wall.
Video 2. Left coronary angiography shows contrast dye filling into the LA through small coronary fistulae from the left circumflex artery. Video 3. Right coronary angiography shows contrast dye filling into the LA through small coronary fistulae from the right coronary artery.
7
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