Treatment of Coronary Artery Fistulas
Large coronary artery fistulas should be closed via transcatheter or surgical approach regardless of symptoms, while small to moderate fistulas require closure only if they cause myocardial ischemia, arrhythmias, ventricular dysfunction, or endarteritis. 1
Treatment Indications
Mandatory Closure
- All large coronary artery fistulas require closure regardless of whether the patient has symptoms 1
- Small to moderate fistulas with any of the following documented complications warrant closure: 1
- Myocardial ischemia
- Arrhythmias (including paroxysmal atrial fibrillation or ventricular arrhythmias)
- Unexplained ventricular dysfunction or enlargement
- Endarteritis
Conservative Management
- Small, asymptomatic coronary artery fistulas can be managed conservatively with clinical follow-up and echocardiography every 3 to 5 years 1
- Small fistulas may close spontaneously over time and generally have excellent prognosis with medical management 2, 3
Treatment Modalities
Transcatheter Closure (First-Line)
- Transcatheter closure is the preferred approach for suitable anatomy due to less invasiveness 1
- Can be performed using coils or other occluding devices 1
- This approach has become increasingly utilized with advancement of equipment and techniques 2
Important caveat: Transcatheter closure carries risks including myocardial infarction, device embolization, and fistula recanalization 2
Surgical Intervention
- Surgical correction is indicated when transcatheter closure is not feasible or has failed 1
- Surgery must be performed by surgeons with specific training and expertise in congenital heart disease 1
- Surgical ligation shows equivalent long-term results compared to transcatheter approach 3
Post-Treatment Follow-Up
- Patients with treated coronary artery fistulas require intermediate and long-term follow-up, as they may still have large, patulous epicardial conduits even after successful closure 1
- Life-long follow-up is essential to monitor for disease progression or cardiac complications 3
Additional Management Considerations
Antibiotic Prophylaxis
- Antibiotic prophylaxis for bacterial endocarditis prevention is recommended in all patients with coronary artery fistulas undergoing dental, gastrointestinal, or urological procedures 3
Diagnostic Workup Before Treatment
- CT angiography or MRI is recommended for detailed anatomical evaluation 1
- Transcatheter delineation of the fistula course and access to distal drainage should be performed in all patients with audible continuous murmur 1
- Cardiac catheterization and coronary angiography are necessary for precise delineation of coronary anatomy, hemodynamic assessment, and identification of concomitant atherosclerosis 4