Asian Cardiovasc Thorac Ann 2000;8:24-26
© 2000 Asia Publishing EXchange Pte Ltd
Surgical Treatment of Coronary Artery Fistula
Gu Chun Jiu, MD,
Zhang Zhi Wei, MD,
Yan De Min, MD,
Gu Tian Xiang, MD,
Yuan Yi Hua, MD,
Xiu Zong Yi, MD
Department of Cardiac Surgery
The First Clinical College
China Medical University
Shenyang, Liaoning, People's Republic of China
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For reprint information contact: Gu Chun Jiu, MD Tel: 86 24 2386 3731 Ext. 6260 Fax: 86 24 2386 2377 Department of Cardiac Surgery, The First Clinical College, China Medical University, 155 North Nanjing Street, Heping District, Shenyang, Liaoning Province 110001, People's Republic of China.
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Abstract
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Six patients with coronary artery fistula were treated surgically between October 1977 and November 1998. The clinical manifestations, diagnostic criteria, indications for operation, and surgical techniques were evaluated. One patient died from ventricular fibrillation on the 2nd postoperative day. The outcome for the other 5 patients was good; symptoms and heart murmurs disappeared and all are alive and well after 10 to 21 years of follow-up. It was concluded that analysis of clinical data can confirm the diagnosis and this condition can be treated satisfactorily by suitable surgery.
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Introduction
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Coronary artery fistula, usually congenital, is a direct communication between a coronary artery and either the lumen of any of the four cardiac chambers, the coronary sinus or its tributary veins, the superior vena cava, pulmonary artery, or the pulmonary veins close to the heart. It is rarely seen clinically.1 In this study, 6 patients with congenital coronary artery fistula who were surgically treated at our department between October 1977 and November 1998, were evaluated with respect to clinical manifestations, indications for operation, and surgical techniques.
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Patients and Methods
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Three of the 6 patients were male. Ages ranged from 14 to 48 years with a mean of 24 years. One patient was asymptomatic and the other 5 complained of palpitations, dyspnea, or symptoms of upper respiratory tract infection (Table 1
). A heart murmur of grade 2 to 4 could be heard over the 2nd to 4th intercostal spaces along the left sternal border. The murmur was continuous in 3 patients and systolic in the other 3. A murmur over the apical area was heard in one patient. There were no increases in pulse pressure.
Electrocardiography revealed left ventricular hypertrophy in 3 patients; biventricular enlargement in 1, arrhythmia (ventricular premature beat) in 1, and no abnormality in the other patient. Echocardiography diagnosed a coronary artery-to-pulmonary artery fistula with abnormal origin of the coronary artery in one patient. Two cases were misdiagnosed as patent ductus arteriosus (PDA), 2 were misdiagnosed as ventricular septal defect (VSD), and 1 was thought to be a pericardial cyst before surgery. Chest radiography misdiagnosed patient no. 1 (Table 1
) as having a PDA because of lung congestion and enlargement of the aortic shadow. In 2 patients (nos. 2 and 3), chest radio-graphs showed enlargement of a segment of the pulmonary artery and left ventricle, which was misdiagnosed as VSD. In patient no. 4, the chest radiograph showed a juxta-cardiac shadow and the preoperative diagnosis was pericardial cyst. Chest radiography in the other 2 patients showed lung congestion, enlargement of a pulmonary artery segment, and left ventricular hypertrophy; one of these patients was diagnosed with a coronary artery fistula by echocardiography.
In patient no. 1 who was misdiagnosed as having PDA, no cardiac catheterization or angiography was carried out and the coronary artery fistula was found at surgery. Cardiac catheterization and angiography were carried out in the other 5 patients. In patient no. 2, a left-to-right shunt was noted at the ventricular level, which was misdiagnosed as VSD. However, a right coronary artery-to-pulmonary artery fistula was found during surgery. In patient no. 3, cardiac catheterization and angiography showed a left-to-right shunt at the ventricular level, which was misdiagnosed as VSD, whereas a right coronary artery-to-pulmonary artery fistula was found at surgery. In patient no. 4, coronary angiography during surgery indicated a fistula from a dissecting aneurysm of the right ventricular wall. Cardiac catheterization in case no. 5 showed a left-to-right shunt at the pulmonary and right ventricular levels, while coronary angiography indicated a left coronary artery-to-right ventricular fistula (Table 1). No cardiac catheterization or angiography was performed in patient no. 6.
Surgical Techniques
For ligation of a coronary artery fistula, the coronary branches and the proximal and distal ends are freed first, the fistula can then be divided and ligated or sutured. A test occlusion for 5 to 10 minutes should be performed before ligation.2,3 If there is no myocardial color change or electrocardiographic disturbance, the operation can proceed. Patient no. 1 was treated by this technique. Tangential arteriorrhaphy is indicated when coronary arteries drain into a ventricle. Pledgetted mattress sutures are placed transmyocardially through the fistulous duct, just beneath the normal coronary artery.4 The fistula can be closed without lacerating the muscle. Patient no. 2 was treated in this manner. Intracardiac closure can be performed under cardiopulmonary bypass. The heart chamber is opened to locate the origin of fistula and the orifice is closed with pledgetted sutures. The heart chamber should be checked thoroughly to avoid leaving any residual fistula.5,6 The coronary artery-to-right ventricular fistula in patient no. 5 and the coronary artery-to-pulmonary artery fistula in patient no. 6 were treated by this technique. For fistulas complicated by aneurysm formation, the coronary artery can be opened at the aneurysmal site allowing the fistula to be closed directly. In patient no. 4, aneurysm formation in the right ventricular wall was found to be in communication with the right coronary artery, the aneurysm was opened for closure of the fistula orifice and excess aneurysmal wall was removed. If the fistula is difficult to close, the proximal and distal ends can be ligated and a bypass graft can be interposed between the ascending aorta and a site distal to the fistula on the coronary artery.3,7 Patient no. 6 was managed by this method.
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Results
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The surgical techniques employed in each of the 6 patients are summarized in Table 1. Patients 1 to 5 recovered uneventfully but the 6th patient died from ventricular fibrillation on the 2nd postoperative day. The heart murmur disappeared in all surviving patients and during follow-up of 10 to 21 years they have all been well with a normal quality of life.
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Discussion
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The majority of patients with coronary artery fistula complain of fatigue, palpitations, and breathlessness. Continuous heart murmurs of grade 2 to 4 can be heard over the pericardial region and the murmurs are usually not confined to the 2nd to 3rd intercostal spaces nor transmitted to the left axilla. The site of the murmur varies with the different types of fistula.2 When the fistula connects with the right ventricle, the heart murmur can be best heard at the 4th intercostal space along left sternal border. When it connects with the right atrium, the murmur can be easily heard at the 2nd intercostal space along the right sternal border. When it connects with the pulmonary artery or left atrium, a heart murmur can be heard at the 2nd intercostal space along the left sternal border. When the fistula drains into the right ventricle, diastolic components of the murmur are dominant, whereas with drainage into the right atrium, the systolic component is apparent.
Generally, on chest radiography, the pulmonary vasculature changes are similar to those in left-to-right shunt anomalies.7 If the coronary artery is markedly dilated, its shadow on the chest radiograph may be mistaken for other pathologic conditions such as pericardial cyst, as in one of our patients. Cardiac catheterization can indicate a left-to-right shunt at a different site. Therefore, the catheterization results should be correlated with other clinical findings in making a diagnosis. Otherwise, misdiagnoses such as PDA, VSD, or rupture of a sinus of Valsalva aneurysm may be made. Retrograde aortic and coronary artery angiography can show the origin, termination, and path of the fistula and can provide the definitive diagnosis.7
Once diagnosed, an operation is indicated in all patients with coronary artery fistula.6 Any coexisting anomalies can be corrected simultaneously or at a later date.8,9 It was concluded from this study that careful analysis of the clinical data can accurately indicate a diagnosis of coronary artery fistula. Suitable surgical techniques can provide satisfactory results in the majority of patients.
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References
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Abstract
Introduction
