Ann Thorac Surg 2008;86:1382. doi:10.1016/j.athoracsur.2007.11.029
© 2008 The Society of Thoracic Surgeons
Images in Cardiothoracic Surgery
Coronary Arteriovenous Fistula With Aneurysm Formation
Jun-Neng Roan, MD,
Chung-Dann Kan, MD,
Yu-Jen Yang, MD, PhD*
Division of Cardiovascular Surgery, Department of Surgery, National Cheng Kung University Hospital and College of Medicine, Tainan, Taiwan
* Address correspondence to Dr Yang, Division of Cardiovascular Surgery, Department of Surgery, National Cheng Kung University Hospital and College of Medicine, 138, Sheng Li Rd, Tainan, Taiwan (Email: yangyj{at}mail.ncku.edu.tw).
A 66-year-old woman was found to have continuous heart murmur for 8 years before this admission. Previous transthoracic echocardiography revealed a primary anomaly of coronary arteriovenous fistula from the left anterior descending coronary artery (LAD) into the main pulmonary artery. She was physically well until this admission, when she complained of dyspnea on exertion.
A computed tomography (CT) angiography with a 16-slice CT (Somatom Sensation 16; Siemens, Malvern, PA; 120 kv, 550 mA, 0.75c) showed a giant aneurysm of the coronary arteriovenous fistula adjacent to left atrial auricle (Fig 1A). The left main and LAD were dilated (not shown). The coronary angiography revealed similar findings and another fistula from the right coronary artery into main pulmonary artery. Considering intraoperative myocardial protection and possible occlusion of the proximal LAD during surgical repair, we used one saphenous vein graft at the distal LAD under cardiopulmonary bypass. The aneurysm was found locating on the right ventricle outlet portion (Fig 1B).
Surgical removal of both coronary arteriovenous fistulae was performed subsequently. The common orifice at the main pulmonary artery was obliterated by direct suture. Unroofing of the aneurysm was performed along the fistula so as to identify the other end of it at the proximal LAD. Interrupted suture was performed to close the defect in the proximal LAD. The procedure was completed with two chest tubes for drainage.
The patient recovered well and was discharged on postoperative day 10. A CT angiography revealed a persistently dilated proximal LAD (Fig 2,
arrow). The saphenous vein graft was possibly occluded because of competitive flow from the native vessel. The patient's daily activity remained in New York Heart Association functional class I.
