Myocardial ischemia in generalized coronary artery–left ventricular microfistulae

• Published in: International journal of cardiology Vol. 63; no. 1; pp. 47 - 52
• Main Authors: Stierle, Ulrich, Giannitsis, Evangelos, Sheikhzadeh, Abdolhamid, Potratz, Jürgen
• Format: Journal Article
• Language: English
• Published: Shannon Elsevier Ireland Ltd 05.01.1998; Elsevier Science
• Subjects: Aged; Biological and medical sciences; Cardiac Catheterization; Cardiology. Vascular system; Cardiomyopathies - complications; Cardiomyopathies - diagnosis; Cardiomyopathies - physiopathology; Congenital coronary–systemic artery fistula; Coronary Angiography; Coronary Disease - complications; Coronary Disease - diagnosis; Coronary Disease - physiopathology; Coronary heart disease; Echocardiography, Doppler; Electrocardiography; Female; Heart; Heart Ventricles; Hemodynamics; Humans; Lactic Acid - blood; Medical sciences; Middle Aged; Myocardial ischemia; Myocardial Ischemia - blood; Myocardial Ischemia - diagnosis; Myocardial Ischemia - etiology; Vascular Fistula - complications; Vascular Fistula - diagnosis; Vascular Fistula - physiopathology; Congenital coronary–systemic artery fistula; Myocardial ischemia; Human; Aneurysm; Coronary artery; Cardiovascular disease; Fistula; Coronary heart disease; Myocardial disease; Left ventricle; Arterial disease; Vascular disease; Ischemia; Etiology; Myocardium; Bibliographic review
• ISSN: 0167-5273; 1874-1754
• DOI: 10.1016/S0167-5273(97)00280-5

Generalized (multiple) arterio-systemic fistulae are fistulae arising from all three major coronary arteries and drain into the left ventricle are rare and the clinical and hemodynamic sequelae are incompletely understood. This communication is based on the clinical and hemodynamic data of a series of patients (eight cases out of 7 262 consecutive patients) incidentally identified at coronary angiography combined with data from cases previously reported in literature. The aim was to assess the role of generalized coronary artery fistulae as a non-atherosclerotic cause of myocardial ischemia by means of a coronary sinus lactate study. Coronary sinus lactate study demonstrated myocardial ischemia in 6/7 patients. Mean arterio-coronary venous lactate difference decreased from 0.31±0.18 mmol/l (lactate extraction ratio, LER, 29.4±13.9%) at rest to 0.04±0.13 mmol/l (LER –4.0±13.3%) at peak exercise. Five minutes after cessation of pacing, lactate difference increased to 0.22±0.21 mmol/l (LER – 20.7±13.2%). At peak pacing stress, 4/7 patients showed frank lactate production, and two patients presented with a reduced cardiac lactate extraction rate also indicating myocardial ischemia metabolically. In the present study, we demonstrated a possible role of a coronary steal mechanism due to microfistulae pathways in the pathogenesis of myocardial ischemia in patients with generalized coronary artery–left ventricular microfistulae.