ABC | Volume 112, Nº2, February 2019

Case Report Kulchetscki et al Coronary artery fistula - clinical treatment Arq Bras Cardiol. 2019; 112(2):211-213 Figure 1 – Comparative image of the coronary fistula (to the left in 2007 and to the right in 2017) - ADA: Anterior Descending Artery; LMCA: Left Main Coronary Artery; Cx: Circumflex Artery; 1Dg: First Diagonal Artery; 1LMgA: First Left Marginal Artery. Table 1 – Evolution of echocardiographic parameters along the years 2007 2013 2016 2017 Left Atrium (mm) 30 37 40 38 Interventricular Septum (mm) 7 9 9 8 LV Posterior Wall (mm) 7 8 8 8 LV Diastolic Diameter (mm) 54 56 58 57 LV Systolic Diameter (mm) 37 38 39 41 LVEF (%) 59 60 60 59 Aortic Sinus (mm) 31 32 33 32 RV Systolic Function Normal Normal Normal Normal Additional findings Mild MR Mild MR. Mild TR. Minimal AR. Minimal systolic displacement of the posterior cusp towards the left atrium. Moderate MR Mild degree TR. Mild PF. Posterior cusp prolapse towards the left atrium. Important MR (eccentric jet directed to the interatrial septum). Qp/Qs ratio of 0.8. LV: left ventricle; LVEF: left ventricular ejection fraction; RV: right ventricle; MR: mitral regurgitation; TR: tricuspid regurgitation; AR: aortic regurgitation; PF: pulmonary failure; Qp/Qs: pulmonary artery and aortic flow ratio. The conservative treatment should be considered in small, asymptomatic fistulas. The fistula spontaneous closure is rare and occurs in only 1-2% of cases. The interventional treatment for CF closure, whether surgical or percutaneous, should be considered in large CFs and inmore proximal locations, presence of symptoms, presence of other cardiovascular diseases / associated cardiac malformations, and hemodynamic repercussion (high-flow fistulas). 5,8 However, these are not complication-free procedures. The surgical treatment can showa high rate of periprocedural myocardial infarction and occurrence of residual tricuspid reflux. 9 Percutaneous treatment with occlusion devices (coils used in small fistulae and Amplatzers used in large CFs) 8,10 may also be complicated by aneurysmal dilatation and thrombosis leading to embolization and myocardial ischemia, as well as device migration ( mainly coils in large, high-flow fistulas). Situations in which occlusion is incomplete favor the occurrence of infective endocarditis and hemolysis. 5,8 In the present case, initially described 10 years ago, of an asymptomatic moderate CF without clinical or hemodynamic repercussions, where we chose to carry out a clinical follow-up, we observed a very favorable evolution, with the patient remaining asymptomatic and with good aerobic (cardiovascular) fitness throughout the period, in the absence of myocardial ischemia and pulmonary hyperflow, with preserved ventricular function, and showing a slight increase in the RC (6 to 7 mm) and the LMCA (7 to 8 mm) diameters, in addition to a slight left chamber dilatation, the latter justified by mitral valve prolapse that developed into significant regurgitation, an association found in some cases. As previously discussed, 1 we emphasize that the conservative treatment is safe and should be carried out in 212