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Youn, Khalid, Azrin, and Lee: Defining Coronary Artery Perforation with Ultrasound Contrast Agent
Images in Cardiovascular Medicine

Korean Circulation Journal 2018; 48(11): 1028-1029.

Published online: 6 September 2018

DOI: https://doi.org/10.4070/kcj.2018.0179

Defining Coronary Artery Perforation with Ultrasound Contrast Agent

Young Jin Youn, MD, PhD1, Salman Khalid, MD2, Michael Azrin, MD2, Juyong Lee, MD, PhD2

1Division of Cardiology, Department of Internal Medicine, Wonju College of Medicine, Yonsei University, Wonju, Korea.

2Division of Cardiovascular Medicine, Calhoun Cardiovascular Center, University of Connecticut School of Medicine, Farmington, CT, USA.

Correspondence to Michael Azrin, MD. Division of Cardiovascular Medicine, Calhoun Cardiovascular Center, University of Connecticut School of Medicine, 263 Farmington Avenue, Farmington, CT 06030, USA. azrin@uchc.edu

Received 25 May 2018       Revised 20 June 2018       Accepted 17 July 2018

Copyright © 2018. The Korean Society of Cardiology

The Korean Society of Cardiology

(open-access, https://creativecommons.org/licenses/by-nc/4.0):

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
After recanalization and stenting a chronic total occlusion of the left anterior descending coronary artery (LAD), coronary artery perforation (CAP) was detected in the LAD (Figure 1A and Supplementary Video 1), but it was not definitive whether this CAP emptied into the pericardium (Ellis classification III) or into the right ventricle (RV) (Ellis classification III cavity spilling).1) Bedside echocardiography showed no definite pericardial effusion. Despite prolonged balloon inflation, spontaneous sealing was not achieved. To define the direction of the CAP, 2 mL of ultrasound contrast agent (UCA), Definity (Lantheus Medical Imaging, North Billerica, MA, USA) was injected into the LAD. The rapid and dense appearance of UCA in the RV on echocardiography confirmed that the CAP was connected to the RV (Figure 1B and Supplementary Video 2). Because there was felt to be no risk of cardiac tamponade the procedure was completed. The patient was hemodynamically stable at discharge and there were no subsequent complications at 1-month follow-up.
Conservative management for this type of CAP is debated, but only a medium or large sized fistula is considered as a cause of heart failure and myocardial ischemia.2)
UCA is used for better endocardial border delineation and assessment of intracardiac blood flow. Recently, the U.S. Food and Drug Administration removed the contraindications for use in patients with cardiac shunts and for administration by intra-arterial injection. Despite a concern about systemic embolization of UCA, several studies have demonstrated the safety3)4) and we used only a small amount of UCA in this case. This case illustrates the utility of UAC for the diagnosis of CAP into a ventricular chamber.

Figures and Tables

Figure 1
Coronary angiography and contrast echocardiography. (A) Post-stenting angiography shows CAP in the LAD (white arrowheads), but it is not definitive whether this perforation emptied into the pericardium (Ellis classification III) or into the RV (Ellis classification III cavity spilling). (B) After injection of UCA into the LAD, the rapid and dense appearance of UCA in the RV on echocardiography confirms the CAP of Ellis classification III cavity spilling.
CAP = coronary artery perforation; LAD = left anterior descending coronary artery; LV = left ventricle; RV = right ventricle; UCA = ultrasound contrast agent.
kcj-48-1028-g001

Notes

Conflict of Interest The authors have no financial conflicts of interest.

Author Contributions Validation: Azrin M, Khalid S; Visualization: Lee J; Writing - original draft: Youn YJ.

References

1. Ellis SG, Ajluni S, Arnold AZ, et al. Increased coronary perforation in the new device era. Incidence, classification, management, and outcome. Circulation. 1994; 90:2725–2730.
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2. Oreglia JA, Bruschi G, Klugmann S. Percutaneous treatment of iatrogenic left-anterior descending artery to right ventricle fistula. Catheter Cardiovasc Interv. 2010; 76:975–977.
crossref
3. Main ML, Hibberd MG, Ryan A, Lowe TJ, Miller P, Bhat G. Acute mortality in critically ill patients undergoing echocardiography with or without an ultrasound contrast agent. JACC Cardiovasc Imaging. 2014; 7:40–48.
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4. Muskula PR, Main ML. Safety with echocardiographic contrast agents. Circ Cardiovasc Imaging. 2017; 10:e005459.
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SUPPLEMENTARY MATERIALS

Supplementary Video 1

Angiography demonstrates perforation of the septal branch of the left anterior descending coronary artery.

Supplementary Video 2

Injection of contrast in the septal branch demonstrates dense opacification of the right ventricle and confirms that the exit site of the septal perforation is into the right ventricle and not into the pericardium.
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ORCID iDs

Young Jin Youn
https://orcid.org/0000-0001-7066-7474

Salman Khalid
https://orcid.org/0000-0003-4638-9675

Michael Azrin
https://orcid.org/0000-0002-2669-0703

Juyong Lee
https://orcid.org/0000-0001-5412-5472

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