Clinical Images

Post Heart Transplantation Coronary Artery Fistula and Coronary Artery Aneurysm Successfully Managed With the Implantation of Covered Stents

Felipe H. Valle, MD, PhD1,2; Bruno S. Matte, MD, MSc3; Joana Brum, MD3; Nadine Clausell, MD, PhD3; Livia A. Goldraich, MD, MSc4

Felipe H. Valle, MD, PhD1,2; Bruno S. Matte, MD, MSc3; Joana Brum, MD3; Nadine Clausell, MD, PhD3; Livia A. Goldraich, MD, MSc4

J INVASIVE CARDIOL 2020;32(7):E191-E192.

Key words: coronary aneurysm, coronary artery fistula, covered stent, heart transplantation

A 62-year-old female patient with refractory exercise intolerance was diagnosed with a large coronary-to-cardiac chamber fistula and coronary aneurysm developed within the first year post heart transplantation (Figure 1). Under intravascular ultrasound guidance, two polyurethane membrane-covered PK Papyrus stents (Biotronik) were implanted in overlap at mid left anterior descending (LAD) coronary artery segment. After postdilation, optimal stent expansion, aneurysm exclusion, and closure of the LAD fistula to the right ventricle were achieved (Figure 2). Mean right atrial pressure decreased by 30%, from 12 mm Hg before procedure to 8 mm Hg after percutaneous coronary intervention. At 6-month surveillance, coronary angiography, sustained fistula closure, and aneurysm exclusion were observed (Figure 2).

Coronary-to-cardiac chamber fistulae and coronary aneurysms are potential complications after heart transplantation, presumably related to the occurrence of myocardium microperforations and direct vascular injury at surveillance endomyocardial biopsies. In the setting of exercise intolerance and large fistulae at major coronary vessels, the possibility of jeopardized myocardial perfusion should be considered. The use of covered stents may provide an effective interventional strategy in this scenario.

From the 1Terrence Donnelly Heart Centre. Saint Michael’s Hospital, University of Toronto, Toronto, Canada; 2Division of Cardiology, Mount Sinai Hospital/University Health Network, Toronto, Canada; 3Division of Cardiology, Hospital de Clinicas de Porto Alegre, RS. Brazil; and 4London Health Sciences Centre, Western University, London, Canada.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein. 

The authors report that patient consent was provided for publication of the images used herein.

Manuscript accepted November 14, 2019.

Address for correspondence: Livia A. Goldraich, MD, MSc, Schulich Medicine & Dentistry Western University, London Health Sciences Centre, St. Joseph’s Health Care, London, Canada. Email: