Balloon test occlusion, device selection, and extracorporeal membrane oxygenation in the transcatheter closure of coronary artery fistula

We read with a great interest the paper by Zoghi et al. (1) entitled “Coil embolization of iatrogenic coronary-pulmonary arterial fistula after heart transplantation” published in the July issue of the Anatol J Cardiol 2015; 15: 587-8. They presented a successful transcatheter coil embolization of iatrogenic coronary-pulmonary fistula after heart transplantation in a 20-year-old male. We congratulate the authors for the successful intervention and clinical management of the case. However, we have a few technical comments. Our major concern is that immediately after release of the coil in the coronary artery, some residual flow is expected, which might potentially mask the evaluation of blood flow in the small right coronary artery efferents regard with ischemia. Therefore, we think that the transient balloon test occlusion of the fistula before releasing the device should be performed in such cases (2). The Amplatzer vascular plug (St. Jude Medical, Austin, TX) device as user-friendly and is attached to a flexible delivery cable that allows us to deliver the device through a smaller delivery catheter. In addition, a single plug is usually enough for the closure of the fistula, and this makes the vascular plug advantageous compared with multiple coil usage, which may result in increased fluoroscopy time, more contrast volume, and higher embolization risk because of high flow in arterial vessels (3, 4). Recently, the use of extracorporeal membrane oxygenation (ECMO) in elective high-risk complex percutaneous coronary intervention has been reported as an alternative method for hemodynamic support (5). In our opinion, it would be more helpful to be prepared for ECMO in hearttransplanted patients with a low systolic ejection fraction and requiring pacemaker support, as in the patient presented by Zoghi et al. (1).