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Ann Thorac Surg 1997;63:1242
© 1997 The Society of Thoracic Surgeons
DR ROSS M. UNGERLEIDER (Durham, NC): I think this was an excellent paper. It is important to have 28-year overviews of topics like this to provide us with some standards of what to expect for these unusual lesions.
I think you have demonstrated unequivocally good results with the standard surgical technique for closure of coronary arteriovenous fistulas even though they can be variable in the ways they present and in their locations.
I have two questions for you. First, can you comment on the role of intraoperative echocardiography in the treatment of these conditions by surgeons? You had 1 patient in your series in whom an intraoperative echocardiogram was performed; since others in the literature, as you know, have suggested that this is a very useful role for the use of intraoperative echocardiography to guide and evaluate the closure of these fistulae, could you comment on what you think the role should be of that modality?
Second, because you are always so expressive in your philosophy about things, could you comment on our role in general as surgeons working with our cardiology colleagues, whether it is in pediatrics like yourself and myself or an adult circumstance, but working with them as teammates rather than as adversaries as they begin to explore ways to treat in the catheterization laboratory problems that we have really enjoyed treating in the operating room? This I know creates anxiety and defensiveness among many surgeons, but should it? I remember very well your comments a few years ago at the annual meeting of The American Association for Thoracic Surgery in response to a surgical colleague using at that time what was the new modality of video-assisted thoracoscopy to clip-ligate patent ductus. Now we are going one step further and seeing how you have to work with cardiology colleagues as you approach similar problems. You have shown the excellent results that they need to be able to achieve. Yet I thought it was interesting that the two of you, you and your associate in cardiology, Dr Rocchini, who is excellent, were able to come to pretty close agreement in which patients to approach in the catheterization laboratory. So I would like to hear you talk about that because all of us face a future in working with our cardiology colleagues as teammates rather than as competitors.
DR DONALD C. WATSON, JR (Memphis, TN): Doctor Mavroudis, this is a landmark paper on an important topic but an infrequent problem. I look forward to seeing it published and actually available on the Internet so all of us can refer back to it about every 2 years, which is about how often this problem comes up for those of us that are doing congenital heart surgery. This paper will be referred to, I can reassure you, by me to try and refresh my memory of your slides and representations of the abnormality.
If you could, I would like you to extrapolate to the adult population, where the disease processes are different. Tell us how best the current practicing cardiovascular coronary artery bypass surgeon could use this information.
DR CHRISTOPHER J. KNOTT-CRAIG (Oklahoma City, OK): We published our similar experience with 7 patients about 3 years ago [1] and had one rather interesting observation that I would like you to comment on: In the younger patients we were able to demonstrate regression in the size of the coronary arteries proximal to the fistulas within 6 months of their surgical repair. Have you looked at this?
Second, can you give us your indications to intervene in these patients, especially those who do not have signs of volume overload?
DR MAVROUDIS: I thank the discussants for their interesting questions.
I acknowledge Dr Ross Ungerleider for his sentinel contributions in the field of intraoperative epicardial and transesophageal echocardiography and for his example, which we follow. We monitor these patients with transesophageal echocardiography not only to confirm fistula closure but also to monitor wall motion abnormalities, which can alert the surgeon to coronary artery perfusion abnormalities that might result from the dissection or ligation.
Now that pediatric cardiologists are performing transcatheter therapeutic interventions, a close working relationship between the surgeon and cardiologist is imperative. Careful, dispassionate views on therapeutic modalities with a primary concern for what is best for the patient usually leads to consensus.
Older patients usually present with symptoms and should undergo some kind of therapeutic intervention. Coronary artery bypass may be necessary in patients with marginal distal coronary artery perfusion. Because we have no long-term follow-up angiograms, we do not have any data on coronary artery size regression after successful fistula ligation. Presently our indications for fistula closure, even in young patients, are the following: (1) Symptomatic patients require intervention for fistula closure. (2) Asymptomatic patients with significant clinical findings should have intervention for fistula closure. Although it is somewhat controversial, we have ligated fistulas in 4 patients who were asymptomatic and had no findings. This posture is more aggressive than reported in other reviews, but we believe that the minimal risks of the operation are justified by the long-term benefits of freedom from eventual symptoms and endocarditis.
Reference
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