Ann Thorac Surg 2008;86:e3. doi:10.1016/j.athoracsur.2008.06.082
© 2008 The Society of Thoracic Surgeons
Images in Cardiothoracic Surgery
Giant Circumflex Coronary Artery Fistula to the Superior Vena Cava in Patient With Multiple Valvular Disease
Christian Muñoz-Guijosa, MDa,*,
Antonino Ginel, MDa,
Ruben Leta, MDb,
Eduard Permanyer, MDa,
Jose Maria Padró, MD, PhDa
a Department of Cardiac Surgery, Hospital de la Santa Creu y Sant Pau, Barcelona, Spain
b Department of Cardiology, Hospital de la Santa Creu y Sant Pau, Barcelona, Spain
* Address correspondence to Dr Muñoz-Guijosa, Hospital de la Santa Creu y Sant Pau, C/Padre Maria Claret 167, Barcelona, 08025, Spain (Email: cmunozg{at}santpau.es).
A 68-year-old man was admitted to our hospital with a history of dyspnea and considerable fatigue with exercise. Transthoracic echocardiography showed severe mitral, aortic, and tricuspid regurgitation. The patient underwent coronary angiography before surgery, which revealed a giant coronary artery fistula arising from the circumflex artery (Fig 1). A multi-sliced computed tomographic scan was performed to delineate the fistula and localize its drainage. Three-dimensional reconstruction showed a tortuous course with multiple loops in the lateral wall (Fig 2) that seemed to end in the pulmonary artery. Intravenous contrast enhancement allowed the location of the drainage orifice in the superior vena cava, near the right atrium.
The patient was operated on through a midline sternotomy. On opening the pericardium, the dilated vessel (arrow) was seen to course from the lateral wall of the left ventricle through the transverse sinus, and it finished at the superior vena cava (Fig 3). It measured 15 mm in diameter. Cardiopulmonary bypass was established (with bi-caval cannulation) after occlusion of the fistula near its drainage. After mitral valve repair, aortic valve replacement, and tricuspid ring annuloplasty, the superior vena cava was opened and explored. The drainage orifice measured 20 mm in diameter and was closed with a running suture. Postoperative recovery was uneventful. The patient was discharged on postoperative day 7.
The most frequent cause of coronary fistula is congenital, with a reported incidence of less than 0.5% [1]. Other causes are iatrogenic and chest trauma [2]. The treatment of this pathology usually consists of surgical ligation or closure [3]. Ligation could be performed in the inflow tract of the fistula with concomitant bypass grafting to the downstream vessel, or it could be performed near its drainage. If it is possible, it is preferable to ligate the inflow tract, which excludes the aneurysmal segment from the blood path and reduces the possible rupture. Great care must be taken when ligating the fistula, due to its very thin and fragile wall.
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- Cheung DLC, Au W-K, Cheung HHC, Chiu CSW, Lee W-T. Coronary artery fistulas: long-term results of surgical correction Ann Thorac Surg 2001;71:190-195.[Abstract/Free Full Text]
- Hancock Friesen C, Howlett JG, Ross DB. Traumatic coronary artery fistula management Ann Thorac Surg 2000;69:1973-1982.[Abstract/Free Full Text]
- Tkebuchava T, Vonsegesser LK, Vogt PR, Jenni R, Arbenz U, Turina M. Congenital coronary fistulas in children and adults: diagnosis, surgical technique and results J Cardiovasc Surg 1996;37:29-34.[Medline]
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