Sapin P, Frantz E, Jain A, Nichols T C, Dehmer G J
C. V. Richardson Cardiac Catheterization Laboratory, University of North Carolina Hospitals, Chapel Hill 27514.
Medicine (Baltimore). 1990 Mar;69(2):101-13.
A coronary artery fistula is an abnormal communication between a coronary artery and a cardiac chamber, great vessel, or other vascular structure. It is an infrequent but potentially important abnormality that can affect any age group. Most are congenital in origin, although other etiologies, in particular trauma, have been identified. Many are small and found incidentally during coronary arteriography, while others are identified as the cause of a continuous murmur, myocardial ischemia, congestive heart failure, or, rarely, bacterial endocarditis. The diagnosis should be considered in any patient presenting with a continuous murmur or in the setting of congestive heart failure, myocardial ischemia, or bacterial endocarditis without an obvious etiology. The pathophysiologic mechanisms resulting in symptoms include cardiac volume overload due to the shunting of blood and reduction of the myocardial blood supply due to "coronary steal." The diagnosis of coronary artery fistula may be suggested by the finding of a continuous murmur in a precordial location, which is atypical for patent ductus arteriosus. Two-dimensional echocardiography may demonstrate dilated coronary arteries, and pulse-wave and color-flow Doppler examinations can display turbulent flow in the suspected fistula and its receiving chamber or vessel. Angiography is generally needed to confirm the diagnosis and elucidate anatomic detail. The natural history of coronary artery fistula is variable, with long periods of stability in some patients and gradual progression of symptoms in others. Small fistulas detected incidentally at the time of angiography do not require immediate surgical correction, but careful follow-up is indicated because the potential for enlargement with physiologically important shunting exists and cannot readily be predicted. Spontaneous closure is uncommon. Surgical repair of the fistula is recommended for symptomatic patients and for some without symptoms because a quantitatively small shunt does not predict freedom from future symptoms or complications. Those selected for medical management must be followed closely.
冠状动脉瘘是指冠状动脉与心腔、大血管或其他血管结构之间的异常交通。它是一种少见但可能具有重要意义的异常情况，可影响任何年龄组。多数起源于先天性，不过也已确定了其他病因，尤其是创伤。许多瘘口较小，在冠状动脉造影时偶然发现，而其他一些则被确定为连续性杂音、心肌缺血、充血性心力衰竭或罕见的细菌性心内膜炎的病因。对于任何出现连续性杂音的患者，或在没有明显病因的充血性心力衰竭、心肌缺血或细菌性心内膜炎的情况下，均应考虑该病的诊断。导致症状的病理生理机制包括由于血液分流引起的心脏容量负荷过重以及由于“冠状动脉窃血”导致的心肌血供减少。冠状动脉瘘的诊断可通过在心前区发现连续性杂音来提示，这对于动脉导管未闭来说是非典型表现。二维超声心动图可显示冠状动脉扩张，脉冲波和彩色血流多普勒检查可显示疑似瘘口及其引流心腔或血管内的湍流。通常需要进行血管造影来确诊并阐明解剖细节。冠状动脉瘘的自然病程各不相同，一些患者病情长期稳定，而另一些患者症状则逐渐进展。在血管造影时偶然发现的小瘘口不需要立即进行手术矫正，但由于存在扩大并出现具有生理重要性分流的可能性且难以预测，因此需要密切随访。自发闭合并不常见。对于有症状的患者以及一些无症状患者建议进行瘘口的手术修复，因为分流定量小并不意味着不会出现未来的症状或并发症。选择进行药物治疗的患者必须密切随访。
