Multimodality cardiac imaging in iatrogenic coronary artery fistula - author's response to: “Insights and observations on post-septal myectomy coronary cameral fistula”
Year: 2024
Type: article
Abstract: We thank Dr Tajik’s team for their letter1 in response to our manuscript describing the role of multimodality imaging in the investigation of a coronary cameral fistulae following surgical myectomy.2 When performed in high-volume centres, surgical myectomy is relatively safe and is the preferred treatment modality when symptoms are refractory to medical therapy.3 Abnormalities of the mitral valve apparatus associated with hypertrophic cardiomyopathy may also contribute to outflow tract obstruction, and, thus, remodelling of the valve may also be required.3 Iatrogenic fistulae are uncommon and usually associated with minor intracardiac shunting and, therefore, may not be recognized on routine post-operative imaging. While the extent and depth of surgical excision no doubt correspond to the risk of iatrogenic fistulae,4 we agree that most follow a benign clinical course and rarely require intervention.5 In our case, resting and stress echocardiography was performed post-surgery to investigate progressive symptoms of exertional dyspnoea and orthostatic hypotension. Repeat baseline imaging revealed a small shunt, which appeared confined to diastole, and considered most consistent with coronary fistula. However, the patient’s limiting symptoms and modest exercise performance prompted an objective exclusion of ischaemia, which may occur in large (and undetected) shunts due to a steal phenomenon. An adenosine myocardial perfusion scan was reassuringly negative for major ischaemia. Though our case emphasized the utility of multimodal imaging, particularly in the post-operative period, pre-surgical cardiac imaging may also play a pivotal role in characterizing the risk of iatrogenic coronary fistulae in patients undergoing surgical myectomy. The high spatial resolution of photon-counting computed tomography may allow clearer visualization of septal perforating vessels and help identify those most at risk of iatrogenic complications by improving surgical planning and management where clinically indicated. Ultimately, cardiac imaging is a critical tool in the assessment and management of patients with hypertrophic cardiomyopathy. The use of multiple imaging modalities is particularly helpful in both planning surgical myectomy and assessing the response to surgical intervention. Funding: None declared. No data are associated with this manuscript.
Authors: James Bowles, Joshua Martin, David J Holland
Language: English
Subfield: Radiology, Nuclear Medicine and Imaging
Field: Medicine
Domain: Health Sciences
Open Access status: gold
Estimated APC paid: $819
OpenAlex ID: W4401856116