title: Prevalence and clinical significance of acquired left coronary artery fistulas after surgical myectomy in patients with hypertrophic cardiomyopathy.
abstract: OBJECTIVE
  The relevance of iatrogenic left coronary artery fistulas complicating surgical myectomy in patients with hypertrophic cardiomyopathy is not known. We prospectively defined the echocardiographic features, prevalence, and clinical significance of left coronary artery fistulas in 40 consecutive patients with hypertrophic cardiomyopathy undergoing extended septal myectomy.
  
  
  METHODS
  Echocardiographic analysis was performed preoperatively and 1 and 6 months after surgical intervention. Diagnosis of left coronary artery fistulas required evidence of diastolic flow draining from the left ventricular wall into the left ventricular cavity according to prespecified criteria.
  
  
  RESULTS
  Left coronary artery fistulas were detected in 9 (23%) of the 40 study patients as a single occurrence in all except 1 patient, who had multiple fistulas. At 6 months, left coronary artery fistulas could still be detected in only 2 of the 9 patients. Of these, 1 patient remained asymptomatic but continued to show left coronary artery fistula persistence at 37 months postoperatively. The other, a woman with prior alcohol septal ablation, had progressive severe symptoms that required percutaneous closure of the fistula with a covered stent after angiographic identification of a large first septal branch fistula associated with distal left anterior descending coronary artery steal.
  
  
  CONCLUSIONS
  In patients with hypertrophic cardiomyopathy, left coronary artery fistulas are common in the early period after surgical myectomy, although their echocardiographic prevalence is dependent on operator awareness. Most left coronary artery fistulas heal spontaneously. Occasionally, however, fistulas can persist and cause symptoms requiring therapeutic intervention.
authors.affiliation: Referral Center for Myocardial Diseases, Careggi University Hospital, Florence, Italy.
authors.forename: Aurelio
authors.initials: A
authors.lastname: Sgalambro
authors.forename: Iacopo
authors.initials: I
authors.lastname: Olivotto
authors.forename: Alessandra
authors.initials: A
authors.lastname: Rossi
authors.forename: Stefano
authors.initials: S
authors.lastname: Nistri
authors.forename: Katia
authors.initials: K
authors.lastname: Baldini
authors.forename: Massimo
authors.initials: M
authors.lastname: Baldi
authors.forename: Pierluigi
authors.initials: P
authors.lastname: Stefano
authors.forename: David
authors.initials: D
authors.lastname: Antoniucci
authors.forename: Francesca
authors.initials: F
authors.lastname: Garbini
authors.forename: Franco
authors.initials: F
authors.lastname: Cecchi
authors.forename: Magdi H
authors.initials: MH
authors.lastname: Yacoub
mesh_terms: D000328:Adult; D000368:Aged; D006348:Cardiac Surgical Procedures / Q000009:adverse effects*; D002312:Cardiomyopathy, Hypertrophic / Q000601:surgery*; D003324:Coronary Artery Disease / Q000000981:diagnostic imaging / Q000453:epidemiology / Q000209:etiology* / Q000628:therapy; D018618:Echocardiography, Doppler, Color; D005260:Female; D006331:Heart Diseases / Q000000981:diagnostic imaging / Q000453:epidemiology / Q000209:etiology* / Q000628:therapy; D006352:Heart Ventricles / Q000000981:diagnostic imaging; D006801:Humans; D007049:Iatrogenic Disease; D008297:Male; D008875:Middle Aged; D015995:Prevalence; D011446:Prospective Studies; D012075:Remission, Spontaneous; D013997:Time Factors; D016896:Treatment Outcome; D016157:Vascular Fistula / Q000000981:diagnostic imaging / Q000453:epidemiology / Q000209:etiology* / Q000628:therapy