Asian Cardiovasc Thorac Ann 2000;8:235-237
© 2000 Asia Publishing EXchange Pte Ltd
Coronary Arteriovenous Fistulas
Serdar Çimen, MD,
Mehmet Kaplan, MD,
Hakan Gerçeko
lu, MD,
Bülend Ketenci, MD,
Batuhan Özay, MD,
Fuat Bilgen, MD,
M Murat Demirta
, MD
Siyami Ersek Thoracic and Cardiovascular Surgery Center
Istanbul, Turkey
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For reprint information contact: Mehmet Kaplan, MD Tel: 90 216 455 7452 Fax: 90 216 337 9719 email: mehmetkaplan{at}superonline.com 67 Ada Kardelen 4-4, D:11 Ataehir, Istanbul 81120, Turkey.
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Abstract
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Between 1988 and 1998, 7 patients with coronary arteriovenous fistulas were treated surgically. Indications for surgery were congestive heart failure and marked left-to-right shunt in association with ischemic heart disease. Long-term follow-up (mean, 99 ± 37 months) was complete and mainly uneventful. Coronary arterio-venous fistulas can be successfully managed by surgery and patients should be treated without delay because complications of an untreated fistula may increase the complexity of the operation.
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Introduction
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Coronary arteriovenous fistula is an infrequently en-countered cardiac pathology. Some controversies still exist regarding the indications and surgical management of this anomaly. Herein, we report our experience and late follow-up of surgically managed cases of coronary arterio-venous fistula.
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Patients and Methods
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Over a 10-year period ending in 1998, 7 cases of coronary arteriovenous fistula were treated surgically at this institution. Most were identified incidentally while performing diagnostic coronary angiography. There were 5 men and 2 women with a mean age of 43 ± 15 years (range, 22 to 61 years). All patients underwent cardiac catheterization and angiography, shunt calculations were carried out according to the Fick principle when needed.
The locations of the fistulas and associated pathology are given in Table 1
. In case 1, one-third of the proximal right coronary artery drained into the right atrium through multiple openings. Although the patient had an asymp-tomatic murmur, she had a high ratio of pulmonary flow to systemic flow (Qp/Qs = 2). The fistulous openings were sutured primarily with 3/0 polypropylene through the right atrium under cardiopulmonary bypass. Two patients had 90% stenosis of the proximal left anterior descending artery and a fistulous connection between this site and the pulmonary artery (Figure 1). The indications for surgery and types of operation are listed in Table 1. Simple fistula ligation with 3/0 pledgetted polypropylene suture was performed without cardiopulmonary bypass only in case 2.
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Figure 1. Angiogram showing a fistula between the proximal left anterior descending coronary artery and the pulmonary artery.
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Results
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No hospital death or complications occurred and all patients were discharged on the 7th postoperative day. Patients were followed up for 99 ± 37 months (range, 34 to 130 months). Annual follow-up was carried out either by telephone interview or at an outpatient clinic. At 3 months and again at 5 years postoperatively, color-flow Doppler echocardiograms were performed; no fistula-related communication was detected. Six patients remained in New York Heart Association functional class I and one (case 3) underwent reoperation because of atherosclerotic coronary heart disease in the 4th postoperative year. At the end of 10 years, all patients were doing well with normal exercise electrocardiograms and all were in New York Heart Association functional class I.
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Discussion
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Coronary arteriovenous fistula, although rare, should always be considered when a continuous thrill or murmur is heard over the chest. The differential diagnosis includes patent ductus arteriosus, ruptured sinus of Valsalva, aortopulmonary window, and repeated endomyocardial biopsies following cardiac transplantation. Such congenital defects are attributed to persisting embryonic intratra-becular spaces that allow communication between the coronary artery and the cardiac chamber.1 The optimal tool for diagnosis and selection of the management pro-cedure is coronary angiography.
Although branches of the left anterior descending and circumflex arteries were the leading locations in this series, the right coronary artery is the most frequently reported site of such fistulas.2 No aneurysms were seen in our cases but a hemangioma was detected on the fistulous tract draining into the pulmonary artery in case 2. Fistulous connections have been found mainly between the right coronary artery and the right ventricle but most fistulas in our patients existed between the left coronary system and the pulmonary artery.2 The fistulas in this study were generally associated with ischemic heart disease (in 4 cases). All of these patients had single-vessel disease but with such a small series, it was difficult to establish whether there was a coincidental or pathogenic relationship between coronary arteriovenous fistula and atherosclerotic ischemic heart disease, although this has been claimed.3
An untreated coronary arteriovenous fistula may lead to congestive heart failure, ischemia, aneurysm formation and spontaneous rupture, or it can become a site of endocarditis.2,4,5 Spontaneous regression is unlikely but possible. None of our patients had an aneurysm or history of endocarditis. Management is either percutaneous embolization or surgical intervention. Surgical techniques depend on fistula location, size, and associated pathology. Simple ligation without cardiopulmonary bypass can be performed in suitable cases where the risk of myocardial ischemia is low. Cardiopulmonary bypass is mandatory only in complicated cases such as fistula aneurysm requiring transvascular repair, or other concomitant procedures.
We recommend that an uncomplicated coronary arterio-venous fistula should be managed surgically without delay if it is symptomatic. In asymptomatic cases, fistula closure should be contemplated if an operation is planned for an associated lesion and there is a marked left-to-right shunt (Qp/Qs > 1.3).6–8
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References
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Castedo E, Oteo JF, Burgos R, Ugarte M, Cristobal C, Tebar E, Ugarte J. Coronary artery fistula as a bypass of a left anterior descending coronary artery stenosis. Ann Thorac Surg 1997;64:1813–4.[Abstract/Free Full Text]
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Abstract
Introduction
