IJCS | Volume 32, Nº2, March/April 2019

194 Jacob et al. Occlusion of coronary fistula in infants Int J Cardiovasc Sci. 2019;32(2)193-196 Case Report by the left circumflex fistula. The angiography revealed mild-to-moderate global LV systolic dysfunction, absence of mitral regurgitation and increased cavity dimensions, without interventricular communication. There was mild pulmonary artery hypertension with elevated RVEDP and RVIDP, elevated right atrium mean pressure and LVEDP. The patient was re-evaluated after 30 days of treatment, with good clinical improvement but, since the fistula was large and had hemodynamic consequences, we decided to perform a percutaneous occlusion. Through puncture of the right femoral artery, a 5F introducer was inserted, through which a guide catheter (Judkins 5F) was introduced, and the left coronary trunk was selectivated. A 0.014” guidewire was introduced through the guide catheter and positioned distally in the left circumflex artery near the right atrium outflow. The guide catheter was removed and an Envoy 5F (Cordis) catheter was introduced over the guidewire and positioned distally in the left circumflex artery. The guidewire was removed and an Amplatzer Vascular Plug I (Figure 2A) was introduced through the Envoy guide catheter, being released in the mean left circumflex artery. After release of the Amplatzer Vascular Plug, which was well adapted, without any mobility, there was a progressive decrease in flow through the left circumflex artery, until complete disappearance of flow through the fistula. Left coronary trunk angiography, performed 30 minutes after plug release, showed complete occlusion of the AVF (Figure 2B), with clear flow improvement in the LAD and LMA due to the elimination of coronary steal. The echocardiographic study performed hours after the percutaneous treatment revealed complete recovery of the LV function (ejection fraction: 71.6%) and absence of flow through the coronary arteriovenous fistula. The patient was discharged on the following day with diuretics (Furosemide and Spironolactone) and an inhibitor of angiotensin-converting enzyme (Captopril). During the 30-day follow-up period he did not present any complications, physical examination showed normalized pulmonary and cardiac auscultation and disappearance of hepatomegaly; echocardiogram showed normal ventricle function (ejection fraction: 68.2%) and absence of flow through the fistula, thus a decision was made to discontinue the medication. Discussion Coronary artery fistulas are rare lesions among the pediatric population, with an approximate incidence of 0.3 to 0.8%, and quite variable clinical manifestation. The most frequent symptom in children younger than 2 years is heart failure, whereas in older children dyspnea on exertion is more prevalent. Complications like myocardial ischemia, embolization and arrhythmia are Figure 1 - (A) Left coronary angiography showing the important dilation of the left coronary trunk and of the left circumflex artery, ending in a blood pool that drains into the right atrium. (B) It shows the blood pool in the end of the course of the left circumflex artery. LCT: left coronary trunk, LCx: left circumflex artery, BP: blood pool, RA: right atrium. Figure 1A Figure 1B