Coronary steal phenomenon following right ventricle decompression and revascularization of atretic left coronary ostium: case report

Background Coronary steal phenomenon and myocardial ischemia is a complication following decompression of a hypertensive right ventricle in patients with left coronary-cameral fistulae. Case presentation We present a 12-year-old girl with a complex heart defect successfully operated on using a hybrid surgical-interventional approach to decompress the ventricle, embolize the fistula and reconstruct the atretic left coronary ostium. Conclusions A novel hybrid strategy is the best solution for coronary-cameral fistulas reliant on high ventricular pressure at high risk for coronary steal phenomenon.

Extracardiac coronary steal induced by upper limb hyperemia: a feature of internal mammary artery arteriogenesis

Introduction Function of naturally existing internal mammary artery (IMA)-to-coronary artery anastomoses has been shown by augmented blood supply to the coronary collateral circulation in response to IMA occlusion. Theoretically, this beneficial functional connection is invertible and can be linked to coronary steal, the verification of whose hypothesis would provide alternate proof to the mentioned functional evidence. Method This was an observational study including 40 patients with chronic coronary syndrome,distal IMA occlusion and upper limb hyperemia (verum group), and 40 propensity score matched controls (placebo group) without IMA occlusion or hyperemia. Primary study endpoint was the inter-group difference and temporal development in coronary collateral function (i.e., collateral flow index, CFI) as obtained at 30, 45 and 60 seconds following a proximal coronary artery balloon occlusion. CFI is the ratio between simultaneous mean coronary occlusive pressure divided by mean aortic pressure both subtracted by central venous pressure. To provoke a steal phenomenon, upper limb hyperemia was induced by upper arm blood pressure cuff deflation following a 5-minute supra-systolic inflation ipsilateral to the sensor-wired coronary artery with release immediately after the first CFI measurement. Results Between the first and the second CFI measurement, CFI change (i.e., CFI@45s minus CFI@30s) was absent in the verum group while there was CFI recruitment in the placebo group: 0.000±0.023 and +0.009±0.013, respectively; p=0.032. Conclusion Among patients with artificial distal IMA occlusion, induction of ipsilateral upper limb hyperemia provokes extracardiac coronary steal as expressed by temporarily absent collateral recruitment as it normally takes place without upper limb hyperemia.

Adenosine‐Induced Coronary Steal Is Observed in Patients Presenting With ST‐Segment–Elevation Myocardial Infarction

Background Adenosine is used to treat no‐reflow in the infarct‐related artery (IRA) during ST‐segment–elevation myocardial infarction intervention. However, the physiological effect of adenosine in the IRA is variable. Coronary steal—a reduction of blood flow to the distal coronary bed—can occur in response to adenosine and this is facilitated by collaterals. We investigated the effects of adenosine on coronary flow reserve (CFR) in patients presenting with ST‐segment–elevation myocardial infarction to better understand the physiological mechanism underpinning the variable response to adenosine. Methods and Results Pressure‐wire assessment of the IRA after percutaneous coronary intervention was performed in 93 patients presenting with ST‐segment–elevation myocardial infarction to calculate index of microvascular resistance, CFR, and collateral flow index by pressure. Modified collateral Rentrop grade to the IRA was recorded, as was microvascular obstruction by cardiac magnetic resonance imaging. Coronary steal (CFR <0.9), no change in flow (CFR=0.9–1.1), and hyperemic flow (CFR >1.1) after adenosine occurred in 19 (20%), 15 (16%), and 59 (63%) patients, respectively. Patients with coronary steal had higher modified Rentrop score to the IRA (1 [0, 1.75] versus 0 [0, 1], P <0.001) and a higher collateral flow index by pressure (0.25±0.10 versus 0.15±0.10, P =0.004) than the hyperemic group. The coronary steal group also had significantly higher index of microvascular resistance (61.68 [28.13, 87.04] versus 23.93 [14.67, 37.00], P =0.006) and had more disease (stenosis >50%) in the donor arteries (52.63% versus 22.03%, P =0.02) than the hyperemic group. Conclusions Adenosine‐induced coronary steal may be responsible for a reduction in coronary flow reserve in a proportion of patients presenting with ST‐segment–elevation myocardial infarction. Registration URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03145194. URL: https://www.isrctn.com ; Unique identifier: ISRCTN3176727.

Coronary steal phenomenon following right ventricle decompression and revascularization of atretic left coronary ostium - case report

BackgroundCoronary steal phenomenon and myocardial ischemia is a complication following decompression of a hypertensive right ventricle in patients with left coronary-cameral fistulae.Case presentationWe present a 12-year-old girl with a complex heart defect successfully operated on using a hybrid surgical-interventional approach to decompress the ventricle, embolize the fistula and reconstruct the atretic left coronary ostium.ConclusionsA novel hybrid strategy is the best solution for coronary-cameral fistulas reliant on high ventricular pressure at high risk for coronary steal phenomenon.

Interpretation of coronary steal syndrome and haemodynamic changes after surgical closure of coronary fistula using Doppler wire and computational fluid dynamics analysis: a case report

Background Coronary arteriovenous fistulas (CAFs) are rare but can cause myocardial ischaemia and other complications. However, the haemodynamic and physiologic characteristics of significant CAFs requiring treatment are poorly described. We report a case of CAF causing coronary steal syndrome in which haemodynamic changes were assessed before and after surgical closure using a Doppler wire and computational fluid dynamics (CFD) technique. Case summary A 51-year-old woman presented with exertional chest pain for 3 years. Progressive dyspnoea occurred with exertion. Treadmill and cardiopulmonary exercise tests showed suspicious myocardial ischaemia. Coronary angiography and contrast-enhanced coronary computed tomography angiography (CCTA) revealed a coronary fistula arising from the distal left main coronary artery that drained into the pulmonary artery trunk. We observed a persistent coronary steal phenomenon at baseline and during hyperaemia and a systolic dominant flow rate pattern inside the CAF by Doppler wire-based flow rate measurement. According to CFD analysis based on CCTA, low wall shear stress and a high focal oscillatory shear index were observed at the ostial sites of aneurysmal sacs in the CAF. After successful surgical closure of the CAF, the vessel sizes and flow rate distributions of the coronary arteries increased. Discussion Doppler wire-based flow rate distribution measurements and CFD analysis may facilitate the identification of significant coronary steal syndrome requiring closure and the evaluation of future risks of life-threatening complications such as thrombosis and rupture.

Stolen from the coronaries: Left-to-Left shunts presenting as chest pain syndrome!

We present the case of a 61-year-old woman with chest pain syndrome. Cardiac catheterisation did not reveal atherosclerotic coronary disease. However, a haemodynamically significant fistula connecting the left coronary artery to the left atrial appendage was found to be the culprit through a left-to-left shunting mechanism. In this report, we review the pathophysiology of coronary artery fistulas and the mechanism by which these fistulas may lead to ‘coronary steal syndrome’. Indications for interventional and surgical management are outlined. Ultimately, we suggest the consideration of coronary artery fistulas in the differential diagnosis of patients presenting with chest pain.

Safe Decompression of the Right Ventricle for PAIVS in Neonates With Coronary Fistulae: Including the Selective Use of Fistula Ligation to Avoid Coronary Steal

Background: There are a number of surgical and interventional treatment options for infants with pulmonary atresia with intact ventricular septum (PAIVS). In our practice, we characterize coronary fistulae and interruptions with angiography in the newborn and have developed a strategy to safely decompress the right ventricle in association with ligation of fistulae if necessary. Methods: All infants operated for PAIVS at age < 60 days from 1999 to 2018 were retrospectively studied. Pre- and postoperative variables were collected, angiograms were reviewed, and a territory score was created to grade the severity of coronary abnormalities. This study focused on the subgroup of patients who had early surgical decompression of the right ventricle. Results: A total of 77 patients were included, with a mean follow-up of 8.6 years. Of these, 55 (71%) had coronary fistulae, including 28 (36%) with coronary artery interruption. Right ventricular decompression (RVD) was performed in 47 (60.5%) patients. There was no 30-day mortality in those who underwent RVD, whereas 6 (20%) without RVD died within 30 days ( P = .003). Ten-year survival was 97.8% and 73.3% for RVD and non-RVD, respectively. In order to prevent coronary steal, 17 patients underwent coronary fistula ligation as their RV was decompressed with 100% early and late survival. Conclusion: Early and late survival in infants with PAIVS is better if the RV can be decompressed. Coronary fistula ligation with RVD has been introduced without an adverse outcome in selected patients with large fistulae.