Cardiovascular Disease |

A Rare Cause of ST Elevation Acute Myocardial Infarction: Coronary Arteriovenous Malformation FREE TO VIEW

Abhishek Mishra, MD; Hari Prasad, MD; Maninder Singh, MD; Sukriti Kamboj, MD; Christopher Bennett, MD; Dwight Stapleton, MD
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RPH/Guthrie, Sayre, PA

Chest. 2013;144(4_MeetingAbstracts):159A. doi:10.1378/chest.1703953
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SESSION TITLE: Cardiovascular Student/Resident Case Report Posters II

SESSION TYPE: Medical Student/Resident Case Report

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: Coronary arterio-venous malformations (AVMs) although rare,can present with a myriad of presentations, ranging from relatively benign to potentially life threatening. We present one such unique case of coronary AVM, presenting as an acute myocardial infarction

CASE PRESENTATION: 60-year-old Male with background history of hypertension, presented to Emergency Department with complaints of typical anginal pain. EKG showed ST elevation in inferior leads. Emergent cardiac catheterization(figure 1) was performed and culprit lesion was deemed to be the obtuse marginal branch of left circumflex artery (LCX). Of particular interest was the unique coronary anatomy. Figure 1 shows severely ectatic coronary arteries with anomalous branches that had origins from the proximal left anterior descending (LAD) & right coronary arteries (RCA). This finding was confirmed on the cardiac CT Angiogram (Figure 2). It is plausible that this acute event happened due to stasis of blood flow in the extremely tortuous arteries, resulting in thrombus formation.

DISCUSSION: Coronary AVMs are often due to deviations from normal embryological development. The majority of coronary AVMs arise from the RCA or the LAD ; the LCX is rarely involved(1,2). Coronary artery dilatation is usual, and the degree of dilatation does not always depend on the shunt size. Over time, progressive dilation of the fistula tract may progress to frank aneurysm formation, intimal ulceration, atherosclerotic deposition, calcification, side branch obstruction, mural thrombosis and rupture(3). The indications for closure are presence of clinical symptoms due to high flow shunting. Though both Surgical and per cutaneous closures are associated with low mortality and morbidity, due to minimally invasive nature, per cutaneous closure has become the method of choice.

CONCLUSIONS: In conclusion, coronary AVMs are rare and associated with variable presentation, ranging from asymptomatic to potentially life threatening Identification of these AVMs associated with high flow shunting is the key to management.

Reference #1: Garcia-Rinaldi R, Von Koch L, Howell JF. Successful repair of a right coronary artery-coronary sinus fistula with associated left coronary arteriosclerosis. Bol Asoc Med P R 1977;69:156- 9

Reference #2: Umana E, Massey CV, Painter JA. Myocardial ischemia secondary to a large coronary pulmonary fistula. Angiology 2002 53 353 7.

Reference #3: Pelech AN. Coronary artery fistula. In: eMedicine [online]. Available at: www. emedicine.com/ped/topic2505.htm.

DISCLOSURE: The following authors have nothing to disclose: Abhishek Mishra, Hari Prasad, Maninder Singh, Sukriti Kamboj, Christopher Bennett, Dwight Stapleton

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