PMC8828911_01
Two-dimensional (2D) transthoracic echocardiogram (TTE) color Doppler showing significant deformation and compression of the right ventricular cavity (red arrow) due to the presence of additional thin-wall round-shaped chamber (white asterisk) (A); two coronary-right ventricle fistulas draining into the additional round-shaped chamber (B); dislocation of the tricuspid valve structures toward the ventricular septum with marked tricuspid flow reduction (yellow arrow) (C); pre-operative assessment by three-dimensional multidetector CT angiography (3D-MDCTA) volume-rendering reconstruction showing entry point (white arrow) (D) and two exit sites (yellow arrows) draining into a round-shaped chamber (red asterisk) (E) within the right ventricle. 3D-MDCTA, three-dimensional multidetector computed tomography angiography; RA, right atrium; RV, right ventricle; LA, left atrium; LV, left ventricle.
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F1
Two-dimensional (2D) transthoracic/transesophageal Echocardiography (TTE/TEE) color Doppler demonstrated preserved left ventricular ejection fraction, mild mitral regurgitation, RV overload (end-diastolic diameter of 3.2 cm), tricuspid annular plane systolic excursion (TAPSE) of 2.1 cm, slightly enlarged right atrium (dimensions 5.5 x 4.3 cm, area 18 cm2), significant compression of the right ventricular cavity by a thin-wall round-shaped chamber resulting in dislocation of the tricuspid valve structures toward the ventricular septum with marked tricuspid flow reduction (Figures 1A-C). At 3-month follow-up, 2D TTE color Doppler showed decompression of the round-shaped chamber, marked increase in the transtricuspid flow due to the tricuspid valve structures re-expansion with significant improvement of right ventricular systolic function (Supplementary Figure 1).
3D-MDCTA volume-rendering reconstruction showing dilated and tortuous right coronary artery and left circumflex artery forming at the base of the heart a distal anastomosis (white asterisk), followed by drainage into the right ventricle through the posterior-lateral wall. 3D-MDCTA, three-dimensional multidetector computed tomography angiography; LM, left main coronary artery; RCA, right coronary artery; LAD, left anterior descending; LCx, left circumflex.
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F2
The patient underwent cardiac catheterization and selective coronary artery angiography in multiple projections showing severely dilated and tortuous RCA and LCx draining distally in a large round-shaped chamber within the RV (Figure 3, Supplementary Videos 2, 3) confirming the diagnosis of two CCFs connecting to the RV. Due to the persistent coronary blood flow across the first implanted coil, two additional 8 cm x 5 mm Gianturco coils were deployed proximally to the Flipper coil achieving complete occlusion of the fistula without compromising the flow in coronary side branches (Figures 4A-D, Supplementary Figure 2). Postprocedure left coronary angiogram showed abolition of the coronary flow by the implanted coils (Figures 4E-H, Supplementary Figure 2).
Baseline right coronary angiogram in LAO 30 - caudal 8  view showing a dilated and tortuous coronary artery (A) draining in a large round-shaped chamber (yellow arrows) within the right ventricle (B) confirming the diagnosis of a right coronary cameral fistula. Baseline left coronary angiogram in RAO 15 - caudal 25  view showing a giant and very tortuous left circumflex (LCx) coronary artery (C) draining through a fistulous path in a large round-shaped chamber (yellow arrows) within the right ventricle (D) confirming the diagnosis of a left circumflex coronary cameral fistula.
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F3
The patient underwent cardiac catheterization and selective coronary artery angiography in multiple projections showing severely dilated and tortuous RCA and LCx draining distally in a large round-shaped chamber within the RV (Figure 3, Supplementary Videos 2, 3) confirming the diagnosis of two CCFs connecting to the RV.
Fluoro-angiographic procedural steps of the coil occlusion of the right coronary (LAO 30  - caud 8 ) and left circumflex (RAO 6  - caud 1 ) coronary cameral fistulas. (A) through a 6-Fr guiding catheter, a Medtronic Resolute Onyx  DES 5 x 15 mm (white arrow) and the Cook Mreye(r) Flipper coil 40 x 5 mm through 6-Fr multipurpose catheter with stylet inside (yellow arrowhead) are concomitantly in place in the distal segment of the right coronary artery (RCA); (B) Resolute Onyx  DES opened and the Cook Flipper coil pinned down by the stent (yellow arrowhead); (C) the Flipper coil is detached and pushed ahead to the stent (black arrow) but still there is residual coronary blood flow; (D) two additional 8 cm x 5 mm Gianturco coils (black small arrows) deployed proximally to the Flipper coil achieving complete occlusion of the fistula; (E) through a Cordis extra back-up (XB) 3.5 guiding catheter, Resolute Onyx  DES 4.0 x 18 mm was opened (white arrow) pinning down the Cook Mreye(r) Flipper coil (yellow arrowhead) delivered through 5-Fr Cobra C1 with stylet inside; (F) balloon of stent withdrawn, 0.014 inch coronary wire in the distal LCx, Flipper's stylet withdrawn and the Flipper coil pushed distally near the stent; (G) two additional Gianturco coils (10 cm x 5 mm + 8 cm x 5 mm) deployed proximally to the Flipper with effective closure; (H) final left coronary angiogram showing abolition of the coronary flow in the distal segment of the LCx by the implanted coils. LAO, left anterior oblique; RAO, right anterior oblique.
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F4
Due to the persistent coronary blood flow across the first implanted coil, two additional 8 cm x 5 mm Gianturco coils were deployed proximally to the Flipper coil achieving complete occlusion of the fistula without compromising the flow in coronary side branches (Figures 4A-D, Supplementary Figure 2). Postprocedure left coronary angiogram showed abolition of the coronary flow by the implanted coils (Figures 4E-H, Supplementary Figure 2).