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Ann Thorac Surg 2001;72:1732-1733
© 2001 The Society of Thoracic Surgeons

Case report

Left circumflex coronary artery to left atrial fistula in a patient with mitral regurgitation after excision of a left atrial myxoma

Andrew C. Burns, FRCSa, Serge Osula, MRCPa, Alexander Harley, FRCPa, Abbas Rashid, FRCS*a

a Divisions of Cardiothoracic Surgery and Cardiology, The Cardiothoracic Centre-Liverpool NHS Trust, Liverpool, United Kingdom

Accepted for publication December 20, 2000.

* Address reprint requests to Mr Rashid, The Cardiothoracic Centre-Liverpool NHS Trust, Thomas Dr, Liverpool L14 3PE, United Kingdom
e-mail: a.rashid{at}ccl-tr.nwest.nhs.uk


   Abstract
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 Abstract
Introduction
 Comment
 References
 
Acquired coronary artery to left atrial fistulas are rare and previously only described in mitral stenosis associated with left atrial thrombus or coronary arteriosclerosis. We present the case of a patient who developed a left circumflex coronary artery to left atrial fistula associated with mitral regurgitation 12 years after excision of a left atrial myxoma. This was successfully ligated at the time of mitral valve replacement.


   Introduction
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 Abstract
 Introduction
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The majority of fistulas between a coronary artery and a cardiac chamber are congenital in origin, but may be acquired in mitral stenosis with left atrial thrombus or arteriosclerosis. We report the case of a patient who had a left atrial myxoma excised, but 12 years later presented with severe mitral regurgitation and a left circumflex coronary artery to left atrial fistula.

A 69-year-old man with longstanding atrial fibrillation had a large pedunculated left atrial myxoma (10 x 7 x 6 cm) excised including wide resection and diathermy of the pedicle base. The pedicle was attached to the posterior left atrial wall just lateral to the septum. Postoperative recovery was uneventful without evidence of mitral reflux on echocardiography. Twelve years later the patient presented with a 4-year history of gradually increasing breathlessness on exertion and, during the previous 12 months, orthopnoea and swelling of the ankles. Physical examination demonstrated controlled atrial fibrillation, a blood pressure of 140/90 mm Hg, a pansystolic murmur, maximal at the apex, and mild ankle edema. An electrocardiogram showed only atrial fibrillation and occasional ventricular extrasystoles. Cardiomegaly caused by atrial enlargement and clear lung fields were seen on the chest roentgenogram. A full blood count and biochemical studies were within normal limits.

Cardiac catheterization showed normal right heart pressures and left ventricular function, moderate mitral regurgitation, and a large left atrium. There was no tricuspid regurgitation or pressure gradient across the mitral or aortic valves.

Coronary angiography demonstrated a fistulous connection between an atrial branch of the proximal left circumflex artery and the left atrium (Fig 1). The native arteries were normal. Trans-esophageal echocardiography confirmed the presence of a jet into the left atrium, without significant shunt.



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  		Fig 1. Preoperative coronary angiogram (left anterior oblique view) demonstrating a fistulous communication between an atrial branch of the left circumflex artery and the left atrium (arrow indicates entrance of the fistula into the left atrium).

 
At operation, utilizing cardiopulmonary bypass, the mitral valve leaflets were myxomatous with no calcification. Organized thrombus was not present in the left atrium. The fistula was found to open at the interatrial groove close to the previous left atriotomy. It was closed by dissecting the feeding artery outside the left atrium, and after ligation was oversewn with 3-0 Prolene (Ethicon, Somerville, NJ), followed by incorporation into the left atrial suture line. The mitral valve was replaced with a 31-mm ATS Medical bileaflet mitral valve prosthesis (ATS Medical Inc, Minneapolis, MN). Mitral valve repair was not undertaken because of excessive leaflet thickening and elongation of chordae to both the anterior and posterior leaflets.

Postoperatively, the patient made an uncomplicated recovery and the systolic murmur disappeared. At 6 months postoperatively, coronary angiography confirmed closure of the left circumflex to the left atrial fistula (Fig 2).



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  		Fig 2. Postoperative angiogram (left anterior oblique view) after closure of the fistula.

 

   Comment
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 Abstract
 Introduction
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References
 
Fistulas between a coronary artery and a cardiac chamber are rare. The majority are congenital in origin and arise equally from the left and right coronary arteries, but predominantly terminate in a right heart chamber [1, 2]. Acquired fistulas are uncommon and have been described in mitral stenosis associated with left atrial thrombus [3, 4] or coronary artery disease [5]. This is a report of an acquired left circumflex coronary artery to left atrial fistula after excision of a left atrial myxoma, and in the presence of mitral regurgitation.

The mechanisms by which acquired coronary artery fistulas develop are unknown. In coronary artery disease, the development of collateral channels or direct communications between a coronary artery and thebesian veins of the atrium, proximal to stenosis of an epicardial coronary vessel can occur [5]. When a left atrial thrombus is present it has been suggested that neovascularization occurs from an adjacent coronary artery and partial necrosis of organized thrombus may result in coronary arterial blood draining into the atrium [6]. In this case, neither a left atrial thrombus nor coronary artery disease was present. It is proposed that the fistula originated from division of an atrial branch of the left circumflex artery running in the left atrial wall at atriotomy at the time of the left atrial myxoma excision. The mural severed end of this atrial branch was then inadvertently incorporated into the left atrial chamber after closure of the atriotomy with subsequent enlargement over the years to form a permanent fistula. The possibility that the fistula could have originated from the severed end of a vessel in the bed of the excised myxoma is unlikely as the opening of the fistula was separate from the site of the myxoma pedicle.

A systolic murmur has been described in a left coronary artery to left atrial fistula [4], but in this patient the pansystolic murmur caused by the severe mitral regurgitation would have made any murmur produced by the fistula inaudible. The etiology of the mitral regurgitation was unknown with no prior history of rheumatic fever.

On the basis of this report, we suggest that large atrial branches encountered at the time of left atriotomy should be ligated separately, and not merely incorporated into the suture line.


   References
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 Abstract
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 Comment
 References
 

  1. Neufeld H.N., Lester R.G., Adams P., Anderson R.C., Lillehei C.W., Edwards J.E. Congenital communication of a coronary artery with a cardiac chamber or the pulmonary trunk. Circulation 1961;24:171-179.[Abstract/Free Full Text]
  2. Levin D.C., Fellows K.E., Abrams H.L. Hemodynamically significant primary anomalies of the coronary arteries. Circulation 1978;58:25-34.[Abstract/Free Full Text]
  3. Fu M., Hung J.S., Lee C.B., et al. Coronary neovascularization as a specific sign for left atrial appendage thrombus in mitral stenosis. Am J Cardiol 1991;67:1158-1160.[Medline]
  4. McClung J.A., Belkin R.N., Chaudhry S.S. Left circumflex coronary artery to left atrial fistula in a patient with mitral stenosis: invasive and noninvasive findings with pathophysiologic correlation. Cathet Cardiovas Diagn 1996;37:52-54.[Medline]
  5. King S.B., Schoonmaker F.W. Coronary artery to left atrial fistula in association with severe atherosclerosis, and mitral stenosi: report of surgical repair. Chest 1975;3:361-363.
  6. Standen J.R. "Tumor vascularity" in left atrial thrombus demonstrated by selective coronary angiography. Radiology 1975;116:549-550.[Abstract]



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