IJCS | Volume 32, Nº2, March/April 2019

DOI: 10.5935/2359-4802.20180100 193 CASE REPORT International Journal of Cardiovascular Sciences. 2019;32(2)193-196 Mailing Adress: Darcio Gitti de Faria Avenida Segunda Damha, 208. Postal Code: 15130-000, Village 2, Mirassol, SP - Brazil. E-mail: darciogfaria@ig.com.br Percutaneous Coronary Arteriovenous Fistula Occlusion in Infants with Left Ventricular Dysfunction Maria Fernanda F. B. Jacob, 1 Darcio Gitti de Faria, 2 J ose Luiz Balthazar Jacob 2 Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo, 1 SP - Brazil Instituto de Moléstias Cardiovasculares, São José do Rio Preto, 2 SP - Brazil Manuscript received Ocotober 25, 2017; revised manuscript May 09, 2018; accepted May 21, 2018. Infant; Coronary Vessel Anomalies; Arteriovenous Fistula; Percutaneous Coronary Intervention; Ventricular Dysfunction Left; Echocardiography, Doppler/methods. Keywords Introduction Congenital coronary fistulas are rare anomalies in which there is connection from the coronary arteries to large vessels or cardiac chambers, without the need for anomalies of number, origin or course of coronary arteries. They usually present in an isolated way, and can have severe hemodynamic consequences. Diagnosed in one of every 50,000 live births, it has an incidence of approximately 0.4% among congenital heart diseases. 1-3 Most of them involve the right coronary artery (50%), followed by the left coronary artery (30%) and both left and coronary arteries (5%). They most commonly drain into a right sided cardiac chamber (more than 90%). 1,4 The clinical presentation depends upon the size and location of the fistula, andmay vary from just auscultation of heart murmurs, in general continuous, to severe heart failure. 5,6 The diagnosis after the clinical suspicion can be confirmed by color Doppler two-dimensional echocardiography, but the angiographic study of the coronary arteries is essential for better anatomical definition and treatment decision-making. 2,7 Nowadays the therapeutic option of choice is the percutaneous occlusion, with excellent short- and long-term results. 1,5,8 Case report Eight-month-old infant, male, born by c-section, weighing 2.9 kg and with a body length of 48 cm, forwarded to our service for assessment due to moaning, fatigue and irritability during breastfeeding. On physical examination, he presented good height and weight development (weight 8.1 kg, length 70 cm), in regular general condition, normal colored, hydrated, acyanotic, tachypneic, withmild intercostal retraction. In respiratory auscultation, he presented mild basal crackles. Cardiac auscultation showed regular rhythm, normal heart sound and presence of a high-frequency continuous murmur in high right sternal border, in addition to a third heart sound in the mitral area. He presented mild hepatomegaly on the palpation of the abdomen. We initiated a treatment of heart failure with diuretics (Furosemide and Spironolactone) and an inhibitor of angiotensin-converting enzyme (Captopril) and requested an electrocardiogram, echocardiogram and chest X-ray. The electrocardiogram did not show any alterations. The echocardiography showed the presence of a left CAF draining into the right atrium and reduced left ventricular ejection fraction (59.8%). The chest X-ray revealed slightly increased heart area. A right and left cardiac catheterization with coronarography was then indicated. The hemodynamic study revealed the presence of a small interatrial communication, with contrast flow to the left atrium – right atrium; dominant right coronary artery of good caliber, and with normal course. The test revealed dilation of left coronary artery trunk extending to the circumflex artery, whichwas enormously dilated in its entire course (Figure 1A), ending in a blood pool that drained through a double-outlet right atrium (Figure 1B). The inferior cardiac vein was filled from the aneurysmal sac. The anterior descending artery showed adequate caliber in its initial portion and tapered in the distal portion, due tomajor steal of coronary flow caused