Segmental degradation of left ventricular wall motion after persistent coronary fistula in a posttransplantation patient - A case report and short review of literature

A 50-year-old man received an orthotopic heart transplant because of severe coronary heart disease and congestive heart failure. Two years after the t ransplantation, a continuous murmur occurred at the left sternal edge after repeated endomyocardial biopsies. Echocardiography and coronary angiograph y revealed a dilated left anterior descending artery with a fistula to the light ventricle, The circumflex was large with an equally postero-lateral b ranch, and the right coronary artery was rather small with collaterals to t he distal part of the left anterior descending branch. The patient had refu sed any intervention to close the fistula, The left ventricular levogram wa s normal. Two years later, in a follow-up angiogram, the left ventricular e jection fraction had decreased as a result of hypo- and akinesis of the ape x and posterior wall. We suggest that this local wall motion disturbance de rives from a steal phenomenon rather than being a sequela of rejection. The decrease in left ventricular ejection fraction was associated with shortne ss of breath upon moderate exercise, Standard heart failure medication reli eved the patient's symptoms. The observation of local wall motion disturban ces in this case, as well as conflicting views in the literature, raises th e question whether postbiopsy coronary fistulas in transplant patients shou ld be closed.