Ann Thorac Surg 2006;82:1106-1107
© 2006 The Society of Thoracic Surgeons
Case report
Sinoatrial Nodal Artery to Right Atrium Fistula After Myxoma Excision
Jason E. Roth, MD, MAJa,*,
William C. Conner, MD, LTCb,
Mary E. Porisch, MD, LTCc,
Eric Shry, MD, MAJa
a Department of Cardiology, Brooke Army Medical Center, Fort Sam Houston
b Department of Cardiothoracic Surgery, Brooke Army Medical Center, Fort Sam Houston
c Division of Pediatric Cardiology, Wilford Hall Medical Center, Lackland Air Force Base, Texas
Accepted for publication January 3, 2006.
* Address correspondence to Dr Roth, 3851 Roger Brooke Dr, Cardiology Service, Brooke Army Medical Center, Fort Sam Houston, TX 78234 (Email: jason.roth{at}amedd.army.mil).
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Abstract
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Acquired coronary artery to cardiac chamber fistulas are rare. Angiographically detectable neovascularization associated with a cardiac myxoma occurs frequently. These vessels are incorporated into the atrial suture line during surgical excision. We describe the case of a patient with a symptomatic right coronary artery to right atrial fistula that had occurred 4 years after left atrial myxoma resection. These large vessels should be considered for ligation during the myxoma resection.
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Introduction
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Fistulas between a coronary artery and cardiac chamber are usually present at birth and occur in 0.17% of patients referred for angiogram [1]. The formation of an acquired fistula between a coronary artery and cardiac chamber is not common, but it has been reported to occur in the presence of atherosclerotic coronary artery disease, a left atrial thrombus with mitral stenosis [2], a nonresected myxoma [3], and rarely into the left atrium after an atrial myxoma resection [2, 4].
A 54-year-old female presented with increasing exertional chest pain and dyspnea associated with new onset of atrial flutter. The patient had undergone surgery for excision of a left atrial myxoma 4 years prior by the superior transseptal approach. Electrophysiology testing demonstrated typical atrial flutter that was successfully ablated. However, the patient continued to have dyspnea on exertion. Perfusion imaging showed inferior ischemia leading to cardiac catheterization. This revealed no obstructive atherosclerotic coronary artery disease. Selective engagement of the right coronary artery revealed a large sinoatrial nodal artery with brisk flow into the superior right atrium near the junction with the superior vena cava (Fig 1), associated with decreased flow to the distal coronary artery. Invasive hemodynamics revealed a pulmonary to systemic flow ratio of 1.5 to 1.
Review of coronary angiography prior to the myxoma resection revealed a large sinoatrial nodal artery arising from the proximal right coronary artery with collateral vessels feeding the myxoma (Fig 2). There was also blood supply to the tumor from a markedly dilated atrial recurrent branch of the left circumflex artery that had since resolved. However, the sinoatrial nodal vessel remnant arising from the proximal right coronary artery was patent and had formed a fistula.
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Fig 2. Coronary angiogram of right coronary artery demonstrating neovascularization of left atrial myxoma prior to resection.
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Due to her symptoms and significant left-to-right shunting with coronary steal, the patient was referred for percutaneous closure of the fistula. After placement of multiple Gianturco coils (Cook Cardiology, Bloomington, IN), the fistula was occluded (Fig 3). The patient's symptoms have resolved. We believe that this is the first report of a right coronary artery to right atrial fistula after myxoma resection.
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Comment
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Cardiac myxomas are the most common cause of primary cardiac tumors representing 30–50% of all cardiac neoplasms [5]. Angiographic evidence of neovascularization occurs in 30% to 40% [5, 6]. These vessels arise from the left circumflex or right coronary arteries in equal distribution [5].
The mechanism of coronary artery to atrial fistula formation after myxoma resection could be related to malposition of the incised ends of the large vessels involved in neovascularization. This mechanism was offered by Burns and colleagues [2] who noted a fistula from the left circumflex artery to left atrium after left atrial myxoma resection. The fistula was seen to involve the proximal cut end of the original branch vessel from the left circumflex supplying the myxoma. The fistula was found to enter the left atrium at the previous left atriotomy site (Sondergaard's groove) [2]. We propose a similar mechanism in our case. The patient had undergone resection of the myxoma by the superior transseptal approach [7]. The tumor had a broad base attachment to the intraatrial septum in the area of the fossa ovalis, and the superior transseptal approach facilitated tumor excision and intraatrial septal patch repair. In this approach the sinoatrial nodal artery is usually divided in the superior portion of the intraatrial septum as the right atrial and septal incisions are connected. The incised ends of the artery are then routinely incorporated into the intraatrial suture line at the completion of the left atrial operation. It is expected that this artery will thrombose. In this case, because of the dilated sinoatrial nodal artery preoperatively, it had a propensity to remain open and ultimately resulted in a fistulous connection with the right atrium. Because the patient also had a large atrial recurrent branch arising from the left circumflex artery, approaching the tumor through Sondergaard's groove could likewise have resulted in a fistulous connection with the left atrium as described by Burns and colleagues [2].
Closure of a fistula between a coronary artery and cardiac chamber can be performed surgically [2], percutaneously with covered stents [4], or with intracoronary coils. Given their rarity and the lack of randomized trials, the closure method chosen should be determined after careful review of each specific case.
Although acquired coronary artery to cardiac chamber fistula is a rare occurrence, it should be expected in clinical situations in which large tortuous coronary collaterals have developed such as with cardiac myxomas. In these circumstances we agree with Burns and colleagues [2] that these specific large branches should be individually ligated rather than simply incorporated into the atrial suture line [2].
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Footnotes
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The opinions or assertions contained herein are the private views of the authors and are not to be construed as reflecting the views of the Department of Army or the Department of Defense.
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References
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- Yamanaka O, Hobbs RE. Coronary artery anomalies in 126,595 patients undergoing coronary angiography Cathet Cardiovasc Diag 1990;21:28.[Medline]
- Burns AC, Osula S, Harley A, Rashid A. Left circumflex coronary artery to left atrial fistula in a patient with mitral regurgitation after excision of a left atrial myxoma Ann Thorac Surg 2001;72:1732-1733.[Abstract/Free Full Text]
- Jorens PG, Van Den Heuvel PA, Van Cauwelaert PA, Parizel GA. Myxoma with a left-to-left shunt and fistula Chest 1989;96:945-946.[Abstract/Free Full Text]
- Hobbs WJC, Kumar S, Roberts DH. Late presentation of an iatrogenic circumflex to left atrial fistula closed with a covered stent J of Interv Card 2003;17(3):179-181.
- Reynen K. Cardiac myxomas N Eng J Med 1995;333(24):1610-1617.[Free Full Text]
- Sasaki Y, Furihata A, Suyama K. A surgically-treated case of left atrial myxoma complicating coronary artery fistula Jpn Heart J 1995;36(6):825-828.[Medline]
- Smith CR. Septal-superior exposure of the mitral valvethe transplant approach. J Thorac Cardiovasc Surg 1992;103:623-628.[Abstract]
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Abstract
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