Asian Cardiovasc Thorac Ann 1998;6:229-231
© 1998 Asia Publishing EXchange Pte Ltd
Minimally Invasive Ligation of Coronary Artery Fistula
Sunil K Kaushal, MCh,
Sitaraman Radhakrishnan, DM,
Krishna S Iyer, MCh
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Department of Cardiothoracic Surgery Escorts Heart Institute and Research Centre New Delhi, India
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For reprint information contact: Krishna S Iyer, MCh Pediatric & Congenital Heart Surgery Escorts Heart Institute and Research Centre Okhla Road New Delhi 110025, India Tel: 91 11 684 4820 Fax: 91 11 683 2605 Email: skkaushal{at}hotmail.com
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ABSTRACT
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Successful surgical occlusion of a left anterior descending coronary artery-to-right ventricular fistula through a minimally invasive route is described. The fistula was ligated epicardially through a small midline pericardial window created in the xiphisternum without myocardial dissection, cardiac arrest, or cardiopulmonary bypass. Intraoperative transesophageal echocardiography played a crucial role in locating the site of the fistula, thereby allowing a minimally invasive surgical approach and assessment of the adequacy of repair.
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CASE REPORT
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A 27-year-old female was referred with a 2-year history of increasing dyspnea on exertion. She was in New York Heart Association functional class III. Examination on admission showed tachycardia of 110 beats per minute with a blood pressure of 140/90 mm Hg. Her apex beat was hyperdynamic and displaced laterally towards the anterior axillary line. On auscultation, a continuous murmur with an associated thrill was heard. There were no signs of chronic heart failure. An electrocardiogram revealed sinus tachycardia and chest radiograph showed right ventricular (RV) cardiomegaly. Transthoracic echocardiography showed a coronary artery fistula between the RV branch of the left anterior descending coronary artery (LAD) and the RV cavity. Estimated pulmonary artery pressures were mildly raised with increased pulmonary blood flows. Subsequently, a coronary angiogram (Figure 1
) confirmed the echocardiographic findings. A dilated tortuous RV branch of the LAD was seen to communicate with the RV cavity via a side branch, while it continued across the RV surface to join the RV branches of the right coronary artery and the distal LAD. The coronary arteries were otherwise normal. Coil embolization of the fistula was attempted without success. The patient was then referred for surgery.
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Figure 1. Coronary angiogram showing left anterior descending (LAD) coronary artery and right ventricular (RV) fistula.
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Pre-ligation intraoperative transesophageal echocardiography located the site of entry of the fistula into the right ventricle, close to the anterosuperior surface on an acute margin of the heart (Figure 2). A minimally invasive surgical approach was applied. The right ventricle was accessed through a small pericardial window created by a 6-cm midline incision continued over the xiphisternum. Operative findings confirmed the preoperative diagnosis. With echocardiographic guidance, the RV branch feeding the fistula was easily identified without myocardial dissection and temporarily occluded epicardially with a 3/0 polypropylene suture encircling the vessel proximal and distal to fistula, without cardiac arrest or cardiopulmonary bypass. Once it was confirmed that there was no residual fistulous flow into the right ventricle and there were no abnormal electrocardiographic or hemodynamic changes after 10 minutes of occlusion of the fistula, the suture was tied to permanently obliterate the fistulous tract under echocardiographic monitoring (Figure 3). The patient made an uncomplicated recovery and was discharged from hospital on the 3rd postoperative day without any cardiac medication. At the 6-month follow-up, she was asymptomatic and her echocardiogram showed good ventricular function and no residual or recurrent fistulous flow.
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Figure 2. Pre-ligation intraoperative transesophageal echocardiograph showing the exact site of the drainage of the coronary artery fistula into the right ventricle. RA = right atrium, RV = right ventricle.
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Figure 3. Post-ligation intraoperative transesophageal echocardiograph showing no residual flow at the junction of the coronary artery fistula and the right ventricle. RA = right atrium, RV = right ventricle, TV = tricuspid valve.
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DISCUSSION
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One of the uncommon congenital anomalies of the coronary circulation is a fistula between a coronary artery and one of the chambers of the heart. Although the term is not entirely accurate, these communications are commonly referred to as coronary cameral fistulas and they have an incidence of between 0.2% and 1%. Such fistulas arise with similar frequency from the right and left coronary systems and drain into a low-pressure venous system, most commonly the right ventricle or right atrium in over 90% of cases.1 Drainage of an otherwise normally distributed LAD into the right ventricle as in this case, is very rare. In embryonic life, the coronary arteries communicate with the veins through an ordinary capillary network. In addition, the arteries have branches to the intra-trabecular spaces or sinusoids, which in turn communicate with the cavities of the ventricles. The sinusoids shrink into a normally calibrated capillary network and the communications with the cavities of the heart are transformed into the thebesian veins. The majority of reported aneurysms seen in childhood were secondary to a coronary artery fistula with a shunt and the exact cause is still unclear. The great majority of infants and children with coronary artery fistulas are asymptomatic. Symptoms tend to occur in older patients who may present with fatigue, dyspnea, angina, or congestive heart failure.2 Liberthson and colleagues2 noted that 80% of patients aged 20 years or less with a coronary artery fistula, were asymptomatic. However, Oldham and colleagues1 reported that among 150 patients with isolated fistulas, 55% had symptoms. Congestive heart failure was seen in 14%, most commonly presenting in either the first year of life or after the age of 20 years. Other complications included endocarditis (5%), aneurysmal formation, and in rare cases, rupture.1,3
Surgical ligation of a coronary artery fistula has been shown to be a safe and effective form of therapy that successfully treats patients with symptoms and protects those without symptoms, usually without significant complications.4,5 However, there are differences of opinion regarding the treatment of patients without symptoms.2–4 We consider that most isolated coronary fistulas can be ligated epicardially without cardiopulmonary bypass under routine intraoperative echocardiography.5 Cardiopulmonary bypass should be reserved for inaccessible lesions or for patients with coexisting cardiac lesions that require repair.4 Transesophageal echocardiography has been shown to accurately assess intraoperative repairs.6 It was used successfully in this case to locate the lesion before surgery, permitting a minimally invasive technique and confirmation of obliteration of the fistulous tract. Advances in port-access and video instrumentation have made laparoscopic and thoracoscopic surgery possible, and the desire to lessen incisional pain and hospital stay has prompted less invasive surgery. Minimally invasive surgery provides better cosmetic results, avoids a long sternotomy and its associated morbidity, with satisfactory results in suitable cases.7 Shorter intensive care unit and hospital stay lessens the financial burden, which is particularly welcome in developing countries.
The comparative therapeutic efficacy of surgery and coil occlusion has not been established. Coronary artery fistulas have been closed using Gianturco coils, balloons, and foam.8 Based on the literature and our personal experience in this case, the requirements for satisfactory coil embolization of a coronary arteriovenous fistula include the ability to safely cannulate the branch coronary artery that supplies the fistula, the absence of large branch vessels that can be inadvertently embolized, the presence of a single narrow restrictive drainage site into the cardiac chambers or vessels, and the absence of multiple fistulous communications.5,8 Transcatheter embolization is a reasonable alternative to surgical closure in only a small group of patients. Surgical results should be considered the standard against which transcatheter techniques are compared. This case confirms the value of intraoperative echocardiography for localization and evaluation of coronary artery fistula ligation, thus allowing a minimally invasive surgical approach.
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REFERENCES
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ABSTRACT
CASE REPORT
