Brit. Heart J., 1969, 31, 400.

Coronary Arteriovenous Fistula with Aneurysm ofCoronary Sinus

ALAN HARRIS, KEITH JEFFERSON, AND KANU CHATTERJEEFrom Cardiac Department, St. George's Hospital, London S.W.1

Abnormal communications of the coronary vascu-lar system are rare, the majority of instances havingbeen described in children or young adults (Gasulet al., 1960; Papaioannou et al., 1962). The com-monest vessel to be involved is the right coronaryartery, and the communication is usually with theright heart chambers or the pulmonary artery.A patient who was asymptomatic for 64 years,

with a coronary artery fistula involving the leftcoronary artery and coronary sinus, is described.

Case ReportA 64-year-old housewife was admitted to hospital in

February 1967, with a 2-week history of palpitation andorthopnoea. There was no previous history of anycardiac disease. On admission she had signs of leftventricular failure confirmed by the presence of pulmon-ary oedema on the x-ray film. Heart rate was 130 aminute, with multiple ventricular ectopic beats, and theleft ventricle was hypertrophied. Blood pressure was185/80 mm. Hg, jugular venous pressure normal, carotidpulse sharp, and there was a grade 3/6 ejection systolicmurmur maximal in the tricuspid area. No obviouscause was found for the left ventricular failure whichrapidly improved with digitalis and diuretics. She wasfollowed as an out-patient where she was seen to befree from heart failure with a normal exercise tolerance,but she continued to have episodes of palpitation lastingup to 30 minutes. During a routine out-patient attend-ance in April 1968, a continuous murmur was heard forthe first time in the left axilla (Fig. 1). The carotidpulses were sharp, the left ventricle hypertrophied, andthe blood pressure was 150/40 mm. Hg. As signs sug-gested an arteriovenous shunt, she was admitted forcardiac catheterization and angiography to determine thesite of the communication. At the time of investigationshe weighed 74-8 kg., height 173 cm., and she was freefrom heart failure.The chest x-ray film (Fig. 2) showed cardiac enlarge-

ment, cardiothoracic ratio 15 *8:29*3. There was anangular projection at the junction of the middle andlower thirds of the left cardiac border. On the x-rayscreening the small projection was best seen in the right

anterior oblique position; this moved down and out withleft ventricular systole, and was not typical of paradoxicalpulsation seen in ventricular aneurysm. The electro-cardiogram showed sinus rhythm, mean frontal axis 0°,left atrial hypertrophy, q lead I, aVL, V4-V7. Otherroutine investigations were normal.

Cardiac catheterization was carried out via a rightantecubital fossa vein and right brachial arteriotomy.The patient was resting at the time of study and was notsedated. The resting pressure and cardiac output werenormal (see Table), but during exercise there was a sig-nificant rise in the mean pulmonary capillary wedge andright ventricular pressures, suggesting impairment ofleft ventricular function. There was no evidence of aleft-to-right intracardiac shunt on serial samples, but ablood sample was not obtained from the coronary sinus.During left heart catheterization the catheter readily

entered an enormously dilated left coronary artery.

Angiography. A No. 8 Mason Sones catheter waspassed into the left coronary artery, and 25 ml. Urografin76 was injected at a pressure of 30 lb./sq. in. BiplaneElema roll films were exposed at 6 a second.The circumflex branch of the left coronary artery was

very wide, measuring 1-5 cm. in diameter. A large ovalaneurysm (8 cm. x 7 5 cm. x 6 cm.) filled from the distalpart of the circumflex artery (Fig. 3, 4, and 5). A fillingdefect within the aneurysm suggested the presence of athrombus. The aneurysm corresponded in position tothe proximal part of the coronary sinus. Later the distalpart ofthe coronary sinus was opacified. It was widenedbut not aneurysmal. Finally the right atrium was out-lined with contrast medium. No filling of the anteriordescending branch of the left coronary artery occurred.This was probably due to a "steal" phenomenon as aresult of high flow through the circumflex artery. Abranch of the circumflex artery was seen to be dilatedand tortuous and undoubtedly emptied into theaneurysm.The grossly dilated proximal part of the circumflex

branch corresponded to the angular projection on theleft cardiac border on the plain chest x-ray (Fig. 2).The posterior bulge of the coronary sinus aneurysmcould be identified on the lateral view of the plain chestx-ray.

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Coronary Arteriovenous Fistula with Aneurysm of Coronary Sinus

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HF:

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401

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FIG. 1.-External phonocardiogram showing the continuous murmur which was localized to the left axilla.PA, pulmonary area; L. axil., left axilla; 1, first heart sound; 2, second heart sound; Insp., inspiration;

L.2., lead II of electrocardiogram; HF, high frequency; CAR., external carotid pulse.

Intracardiac Phonocardiography. The continuousmurmur was localized to the left coronary artery andwas maximal well down the artery at the level of thelarge aneurysm. An ejection systolic murmur wasrecorded in the aortic root and left ventricular outflowtract.

Progress. Despite the tempting possibilities of a sur-gical cure, conservative management was recommendedin the first instance in view of the patient's age, moderateobesity, and good symptomatic response to medicaltreatment.

Discussion

The radiological appearances in this patient corre-spond to the post-mortem findings in a patient re-ported by Davison, McCracken, and McIlveen(1955), where the circumflex branch of the leftcoronary artery was grossly dilated and communi-cated with the coronary sinus which was aneurysmaland formed a thin-walled bag 10 cm. in diameter.

Coronary artery fistulae can usually be demon-strated by aortography (Newcombe, Whitaker, and

TABLECARDIAC CATHETERIZATION DATA

Pressure (mm. Hg) measured from Blood samplesSite sternal angle

Systolic Diastolic Mean 02 content 02 per centvol. per cent satn

Pulmonary capillary wedge - - 6 - -

Right pulmonary artery 34 14 24 12-6 76Left pulmonary artery 34 14 24 12-3 74Main pulmonary artery 34 14 24 12-3 74High right ventricle 31 3 - 12-5 75Low right atrium - - _ 12 0 72Mid right atrium - - 3 a=4 11-6 70High right atrium - - - 11*1 61Superior vena cava - - - 11-3 68Inferior vena cava - - - 11-3 68

Central aorta 150 70 - 16-6 98Left ventricular cavity 150 3 - 16-6 98

Resting cardiac output 5-7 1./min. (Fick) -

Oxygen uptake 246 ml./min. -

Exercise-straight leg raisingPulmonary capillary wedge - - 32Right ventricle 60 4 -

Right atrium - - 7 a= 10

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Harris, Jefferson, and Chatterjee

FIG. 3.-Selective injection into left coronary artery. Thecircumflex branch is grossly dilated. The aneurysm of the

coronary sinus is beginning to fill.

FIG. 2.-Postero-anterior chest film. Cardiac enlargement.Localized bulge on left cardiac border, subsequently shownto be due to a portion of the dilated circumflex branch of the

left coronary artery.

FIG. 4.-Half second later than Fig. 3. The coronary sinusaneurysm is densely opacified. A central filling defect sug-gests thrombus. The distal part of the coronary sinus is

widened but not aneurysmal.

FIG. 5.-Lateral view is synchronous with Fig. 3. Theaneurysm corresponds in position to the proximal part ofthe coronary sinus. The circumflex artery appears to be

displaced somewhat forward by the aneurysm.

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Coronary Arteriovenous Fistula with Aneurysm of Coronary Sinus

Keates, 1964), but undoubtedly a better demonstra-tion of the abnormal anatomy can safely be obtainedwith selective coronary angiography, by the intro-duction of a large volume of contrast medium in-jected under pressure.The absence of a continuous murmur in our

patient during her first admission to hospital wasthought to be due to left ventricular failure. Aftersuccessful treatment, a continuous murmur wasdetected in the left axilla, and it was of interest thatthe intracardiac phonocardiogram located the mur-mur within the left coronary artery at the level ofthe aneurysmal dilatation of the coronary sinus. Ina third of patients with coronary arteriovenous fis-tula, the site of the continuous murmur is indistin-guishable from that of a patent ductus (Gasul et al.,1960). However, in the remainder, the continuousmurmur has an unusual location, as in this patient.The absence of cardiac symptoms for 64 years in

this patient indicates the benign course that coronaryarteriovenous fistulae may run. Since surgical clo-sure of the fistula may be difficult, we felt that wewere not justified at present in recommending sur-gery, particularly with the marked symptomaticimprovement obtained with digitalis and diuretictherapy.

SummaryA 64-year-old woman presented with clinical and

radiological signs of left ventricular failure. Aftermedical treatment a continuous murmur was heardin an unusual site (left axilla) and raised the possi-bility of a coronary arteriovenous fistula. Further-more, the chest x-ray showed an abnormal bulgewhich corresponded well to the position of themurmur.The fistula was demonstrated radiologically by

selective coronary arteriography, with a pressureinjection of a large volume of contrast into the leftcoronary artery, its circumflex branch communicat-ing with an aneurysmal coronary sinus.

Intracardiac phonocardiography localized the con-tinuous murmur to within the left coronary arteryat the level of the aneurysmal coronary sinus.

ReferencesDavison, P. H., McCracken, B. H., and McIlveen, D. J. S.

(1955). Congenital coronary arterio-venous aneurysm.Brit. HeartJ., 17, 569.

Gasul, B. M., Arcilla, R. A., Fell, E. H., Lynfield, J., Bicoff,J. P., and Luan, L. L. (1960). Congenital coronaryarteriovenous fistula. Clinical, phonocardiographic,angiocardiographic and hemodynamic studies in fivepatients. Pediatrics, 25, 531.

Newcombe, C. P., Whitaker, W., and Keates, P. G. (1964).Coronary arterio-venous fistulae. Thorax, 19, 16.

Papaioannou, A., Agorogiannis, S., Nihoyanopoulos, J., andLazzaridis, D. (1962). Congenital coronary arteryfistula. Successful preoperative diagnosis and surgicalcorrection. Amer. J. Cardiol., 10, 588.

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