Stierle U, Giannitsis E, Sheikhzadeh A, Potratz J
Curschmann Klinik, Department of Cardiology (Internal Medicine II) Medical University, Lübeck, Germany.
Int J Cardiol. 1998 Jan 5;63(1):47-52. doi: 10.1016/s0167-5273(97)00280-5.
Generalized (multiple) arterio-systemic fistulae are fistulae arising from all three major coronary arteries and drain into the left ventricle are rare and the clinical and hemodynamic sequelae are incompletely understood. This communication is based on the clinical and hemodynamic data of a series of patients (eight cases out of 7262 consecutive patients) incidentally identified at coronary angiography combined with data from cases previously reported in literature. The aim was to assess the role of generalized coronary artery fistulae as a non-atherosclerotic cause of myocardial ischemia by means of a coronary sinus lactate study. Coronary sinus lactate study demonstrated myocardial ischemia in 6/7 patients. Mean arterio-coronary venous lactate difference decreased from 0.31+/-0.18 mmol/l (lactate extraction ratio, LER, 29.4+/-13.9%) at rest to 0.04+/-0.13 mmol/l (LER -4.0+/-13.3%) at peak exercise. Five minutes after cessation of pacing, lactate difference increased to 0.22+/-0.21 mmol/l (LER -20.7+/- 13.2%). At peak pacing stress, 4/7 patients showed frank lactate production, and two patients presented with a reduced cardiac lactate extraction rate also indicating myocardial ischemia metabolically. In the present study, we demonstrated a possible role of a coronary steal mechanism due to microfistulae pathways in the pathogenesis of myocardial ischemia in patients with generalized coronary artery-left ventricular microfistulae.
广泛性（多发性）动-体循环瘘是指起源于所有三支主要冠状动脉并引流至左心室的瘘，较为罕见，其临床和血流动力学后果尚未完全明了。本报告基于一系列患者（7262例连续患者中的8例）在冠状动脉造影时偶然发现的临床和血流动力学数据，并结合文献中先前报道的病例数据。目的是通过冠状窦乳酸研究评估广泛性冠状动脉瘘作为心肌缺血非动脉粥样硬化病因的作用。冠状窦乳酸研究显示7例患者中有6例存在心肌缺血。静息时平均动-冠状静脉乳酸差值从0.31±0.18 mmol/l（乳酸摄取率，LER，29.4±13.9%）降至运动峰值时的0.04±0.13 mmol/l（LER -4.0±13.3%）。起搏停止5分钟后，乳酸差值增至0.22±0.21 mmol/l（LER -20.7±13.2%）。在起搏应激峰值时，7例患者中有4例出现明显的乳酸生成，2例患者心脏乳酸摄取率降低，也从代谢方面提示心肌缺血。在本研究中，我们证明了在广泛性冠状动脉-左心室微瘘患者中，微瘘途径导致的冠状动脉窃血机制在心肌缺血发病机制中可能起作用。
