Coronary Artery-Ventricular Pseudoaneurysm Fistula After Myocardial Infarction.

A 56-year-old man presented to the emergency department with chest pain. The diagnosis of acute myocardial infarction caused by a left circumflex artery occlusion was made. After conservative treatment, a fistula between the circumflex artery and the left ventricle, and the evolution of the pseudoaneurysm, were noted. (Level of Difficulty: Advanced.).

A 56-year-old man presented to the emergency department with a 7-day history of chest pain. On admission, his vital signs were as follows: temperature 36.6 °C, heart rate 86 beats/min, blood pressure 102/75 mm Hg, and pulse oximetry 95% on room air. Cardiac auscultation on admission revealed normal S1 and S2 with no murmurs or additional heart sounds. His legs were notable for 3–4+ bilateral pitting edema with a negative Homan sign and no erythema. Electrocardiography revealed ST-segment elevation in leads II, III, aVF, and V2 to V6. Echocardiography revealed pericardial effusion. Emergency coronary angiography revealed 3-vessel disease with an occlusion of the left circumflex artery, which had good collateral flow from the right coronary artery distal to the occlusion, thus demonstrating that there was no fistula. Cardiac tamponade caused by ventricular wall rupture after acute myocardial infarction was diagnosed. Considering the risk of recurrence of ventricular rupture, we advised the patient to undergo surgery, including pericardial drainage, ventricular wall repair, and coronary artery bypass grafting. However, he consistently refused invasive treatment; therefore, we provided conservative treatment with single antiplatelet therapy, a β-blocker, and an angiotensin receptor blocker. Angiography performed after 1 month revealed spontaneous recanalization of the circumflex artery with a fistula between its distal end and the posterolateral wall of the left ventricle (Figures 1A and 1B, Video 1). Subsequent echocardiography revealed a defect in the posterolateral wall of the left ventricle (Figure 1C), which was indicative of a pseudoaneurysm. Therefore, acquired coronary artery–ventricular pseudoaneurysm fistula, a rare complication of myocardial infarction, was diagnosed. Five months after discharge, evolution of the pseudoaneurysm was noted (Figure 1D); however, the patient’s condition was stable, and he had no symptoms of heart failure. There has been only 1 reported case in which an acquired coronary fistula communicating with the ventricle pseudoaneurysm emerged secondary to myocardial infarction, which was repaired surgically. We encountered a case of rapid pseudoaneurysm enlargement as a part of the natural history of ventricular pseudoaneurysm, demonstrating that early surgical repair should be strongly considered in such cases.

Figure 1

Coronary Artery Fistula

Coronary artery fistula between the distal end of the circumflex artery and wall of the left ventricle (arrows). (A) Right anterior oblique view. (B) Left anterior oblique view. Echocardiographic images in the parasternal short axis view (C) revealing a pseudoaneurysm on the posterolateral wall of the left ventricle 1 month after admission and (D) showing an enlargement of the ventricular pseudoaneurysm 5 months after discharge.

Funding Support and Author Disclosures

The authors have reported that they have no relationships relevant to the contents of this paper to disclose.