IJCS | Volume 32, Nº2, March/April 2019

195 Figure 2 - (A) It shows the Envoy (Cordis) guide catheter, with the Amplatzer Vascular Plug I already exposed (arrow), but still stuck to the liberator cable. (B) Left coronary angiography performed after 30 minutes from liberation of the device (arrow), showing total occlusion of the left circumflex artery fistula to the right atrium. Figure 2A Figure 2B Jacob et al. Occlusion of coronary fistula in infants Int J Cardiovasc Sci. 2019;32(2)193-196 Case Report more frequent after the second decade of life in large- caliber fistulas. 2,9 The vast majority of anomalies involve the right coronary artery, with drainage into the venous circulation (right ventricle, right atrium, pulmonary artery and venous sinus); the left coronary is rarely involved. 5,7,8 The clinical diagnosis is suspected by the symptomatology and exclusion of other heart diseases that may progress with similar symptoms, but with a cardiac murmur showing different characteristics (patent ductus arteriosus, aortopulmonary window, pulmonary arteriovenous malformations, and pulmonary vein stenosis). 2 Two-dimensional echocardiography can reveal the consequences of the lesion (dilated chambers and coronary arteries, ventricular dysfunction and elevation of Qp:Qs), and in some cases, it allows for the direct visualization of the fistula and its track. 3,7 The previous hemodynamic study is essential, because it assesses in detail the anatomy and the site where the fistula drains, allowing for more accurate and less risky therapeutic decision-making. According to the most recent guidelines, there is consensus that all symptomatic patients should be treated. Occlusion of large fistulas is recommended regardless of symptoms; small- to moderate-sized fistulas, when there is evidence of ischemia, arrhythmia, endarteritis or ventricular dysfunction. 10 The procedure remains limited when the anatomy of the fistula is not favorable, i.e., when there is a native coronary branch distally to the fistula and high risk for prosthesis embolization. Although the surgical correction presents a low morbimortality rate and good long-term evolution, nowadays the method of choice for the treatment of coronary fistulas is percutaneous, due to its low cost, length of hospital stay and reduced complications. 5,6,8 European and Asian cohorts present favorable results in the short and long term, with the elimination of the flow through the fistula and resolution of complications and symptomatology in the vast majority of patients undergoing percutaneous occlusion. 5,6,8 Recently, several single and combined devices have been developed and their techniques for implantation have been improved. 5,8 The most frequently used are the Amplatzer Duct Occluder, Amplatzer Vascular Plug and flipper coils. 5 A previous and thorough evaluation of the fistula geometry and size is crucial to guide the choice of the best device or combinations of occlusion methods. We reported the case of left coronary arteriovenous fistula occlusion in an eight-month infant, with sintomatologyof heart failure andventriculardysfunction. The diagnosis was confirmed by echocardiography and the cardiac catheterization was important to assess the fistula size, its hemodynamic consequences and to define the treatment plan. In this report, as well as in the last studies, there were no complications during or after the procedure. The left ventricle function was recovered