Mazeni Alwi Institut Jantung Negara

(National Heart Institute) Kuala Lumpur

Malaysia

Coronary AV fistula – When to close

by catheter or surgical approach

5th Asia Pacific Congenital & Structural Heart Intervention Symposium 2014 (APCASH) 10 – 12 October 2014, Hong Kong Convention & Exhibition Centre

Justification for closure…

Lithbertson et al. Circulation

174 cases Operative mortality 1% in patients <20 years, 7% in those >20 years

(operative complications 7% vs 23%)

Younger patients were less likely to be symptomatic or have

complications related to CAF (19%), 63% in those >20 years Late complications

Cardiac failure Angina from coronary steal Rupture and tamponade Thrombosis and infarction Arrhythmia

Interventional era

Rare, very varied morphology

Majority of CAF are amenable to transcatheter closure – coils, Amplatzer line of device (vascular plug, ADO I, ADO 2, mVSD device …)

Frequently shown at live case demonstrations Good learning points for assessment of

morphology and techniques of closure

Reasonable body of literature on techniques and early results of transcatheter closure ? Antiplatelet/anticoagulation management ? Medium and long term outcome

When to close CAF …

Transcatheter closure – when is the optimum time?

When is surgical closure preferable?

When is non-closure (no treatment) preferable?

Coronary artery fistula

Usually in younger age group

Often single, not tortuous

Shunt limited by narrowed opening to sink – no symptoms

Heart failure – uncommon (no distal constriction)

Continuous murmur

Usually in older children / adults Tortuous, often multiple No obvious constriction Soft murmurs, silent + Chest pain

Large fistula (>2 x native vessel diameter)

Small fistula (<1.5 x native vessels diameter)

Group A (n=18) Large CAF (>2 x native vessel)

Group B (n=8) Small CAF (<1.5 x native vessel)

Median age (yrs) 8 (1-51) 7 (1-65)

Median weight* (kg) 20 (7.5-60) 14 (4-75)

M:F 5:13 4:4

Symptoms: a)Congestive cardiac failure b)Myocardial ischemia

1 (5.5%) 0 (0%)

1 (12.5%) 2 (25%)

Diameter (mm) 9.8 (5.4-19.9) 3.3 (2.7-4.0)

No. of feeders 1 2 3 4

17 (94%) 1 (6%) 0 0

1 (12%) 5 (64%) 1 (12%) 1 (12%)

Presence of discreet stenosis* 18 (100%) 2 (25%)

Tortuosity** (2 or more acute bends)

0 8 (100%)

Institut Jantung Negara (National Heart Institute), Kuala Lumpur, Malaysia

1994 – 1997 Table 1 : Patient Characteristics

Transcatheter closure … when ?

Coils – delivered via end hole diagnostic catheters 5-6F (flexible enough) but multiple coils often required, ↑ risk of coil migration

ADO, ADO II, mVSD device, vascular plugs … Highly effective, small risk of migration but requires delivery

sheath (+ dilator – very stiff) + need to create A-V loop Catheters, sheath, wires inside coronary arteries … preference

for closure >5 years of age unless the patient is symptomatic or CAF conduit is aneurysmal

Viable myocardial branches in proximity site of device placement – allows more room for manoeuvre in bigger patients

Large coronary artery fistula

7 years, M Circumflex to RV apex, closure with Gianturco coils

Improvement of flow into normal branches post occlusion of fistula

Gabriel1&2

5 years, M Circumflex to RA AV loop for balloon occlusion test and angiogram, ADO delivery transvenous

Ayuni1&4

6 years, F RCA to RA AV loop for multi-track catheter and delivery sheath Closure with mVSD device

Kwoo1-4

5 years, F LCA to LV

Kwoo5&6

5 years, F LCA to LV Closure with ADO II

Transcatheter closure of small CAFs

Very tortuous, may be multiple Often no obvious discreet constriction Presentation at older age : Soft murmur, occasionally chest pain (coronary

steal)

9 years, F, small multiple CAF, LCA to RV 45 years, M, Single small CAF, LCA to MPA, steal symptom

Should be done at older age – manoevering of wires and catheters in small tortuous vessels - ↑↑ risk in small children

Small CAFs

GDC platinum microcoils - released by passage of electrical current (electrolysis)

Delivered via infusion catheter (Rapid transit by Cook with 0.021” lumen, Tracker by Target Therapeutics 0.018” lumen) coaxially with diagnostic coronary catheters

Electrical power supply

Diagnostic coronary catheter

Infusion catheter for coil delivery

Coil pusher

Coil pusher wire

Electrolytic detachment of coil

18 years, M “Small CAF”, LAD to RV Platinum microcoils delivered via infusion catheter within JL diagnostic catheter

Small CAFs

Small size, arising from mildly dilated RCA/LCA, close to many normal branches, coming off at difficult angles

Needs precise coil placement deep in target vessel to avoid ischaemia/infarction

Accessible by small 3F infusion catheter over coronary guidewire to navigate multiple acute bends

Use of controlled release platinum microcoils

ADULT CARDIOLOGY SUPPORT ESSENTIAL (choice of wires, catheter manipulation)

9 years, F, small, multiple CAF LCA to RV

Closure of small, tortuous CAF

coils

Use of platinum microcoils Better flow into feeder artery after elimination of ‘steal’

45 years, M, Single, small fistula, LCA to MPA

When is surgical closure preferable

5 year, F, asymptomatic, continuous murmur, RCA fistula to RV, Normal branches arising off the fistula near exit point

Presence of myocardial branches near intended site of device placement (site of constriction)

Large CAF with no constriction – large L R shunt, cardiac failure (usually neonatal/early infancy presentation)

No constriction to hold device in place, ↑↑ risk of migration Stiff sheath + dilator in coronary artery of small infants !

Conclusions

Largely amenable to transcatheter closure – coils, Amplatzer devices, microcoils for small tortuous fistula

Timing of intervention: >5 years if asymptomatic Risk of maneuvering of catheters, wires and sheaths in coronary artery of

young children Much old age for tortuous, small fistula

Cases for surgery – myocardial branches arising at/near site of intended device placement, large CAF with no constriction

TIMING : >5 years if no symptoms

Increasing reports of coronary events post closure ? Role of non-intervention for CAF high risk of thrombosis ? More aggressive anticoagulation regime post closure

Thank you

Ayuni2&3

Exit point near right A-V grove Use of torque-vue sheath for delivery of ADO Distal branches not occluded by ADO