Discussion
The majority of coronary artery fistulae are asymptomatic as they are
hemodynamically not significant and are incidentally identified by
coronary angiography, CT angiogram, echocardiogram or multi-detector row
computed tomography (MDCT) with 3D reconstruction.[4]. Penetrating
chest injuries causing coronary artery fistula are rare [5].
Moreover, presentation of patients may differ from lack of symptoms to
heart failure or pulmonary hypertension [6,7]. However, most
fistulas are hemodynamically non-significant with CT angiogram,
echocardiogram or multi-detector row computed tomography (MDCT) as a
diagnostic method [4]. We presented the first case of nail gun
injury to the left ventricle with the coronary artery fistula to the
left pulmonary artery presenting with unstable angina presenting after 4
years of asymptomatic course.
PubMed database was reviewed for relevant English literature from 1980
to 2020 using the keywords “nail gun”, “coronary artery fistula”,
and “cardiac trauma”. Twenty-three cases of nail gun injury to the
heart were found, with right chambers most commonly involved as
penetration site (Table 1.). Unlike our patient, most cases presented
acutely and required urgent surgical removal of the nail. Chest x-ray,
CT, intraoperative transesophageal echocardiogram were used as modality
of choice for diagnosis of patients and guidance throughout the
management plan. However, due to the presentation of our patients with
unstable angina and his chronic presentation, we decided to do a
coronary angiogram which revealed abnormal vascular mesh between the
right coronary artery and the left pulmonary artery.
Treatment approach depends on the case presentation; either the
thoracotomy or median sternotomy are acceptable. However, the choice is
mainly guided by the hemodynamic status and the location of the
penetration. There are few cases in which both median sternotomy and CPB
that has the advantage of providing a controlled field that allows for
manipulation and movement of the heart without the risk of circulatory
compromisation or arrhythmia. In this case We used CPB with median
sternotomy without cardioplegia.
Traumatic coronary artery fistulae due to penetrating chest injuries are
rare . Patients may present with congestive heart failure, pulmonary
hypertension, or endocarditis. However, most patients may stay
asymptomatic [6,7]. Treatment options for symptomatic patients may
include (1) surgical correction with ligation of feeding vessels of the
the coronary artery fistula [8] with or without bypass grafting of
the distal vessel, (2) percutaneous closure either with coil
embolization, or covered stent [9]. However, there are currently no
well-designed guidelines for deciding whether and how to treat a
coronary-pulmonary artery fistula.