Minimal invasive coronary artery fistula ligation.

A coronary artery fistula was surgically ligated in a 38-year-old woman via a left anterior mini-thoracotomy without the use of cardiopulmonary bypass. In selected cases, this surgical approach can provide an excellent surgical exposure for coronary artery fistula ligation. It also offers an excellent cosmetic result and shorter hospital stay.

CASE REPORT

A 38-year-old woman presented with a six-month history of progressive exertional dyspnea and a new onset of syncopal episodes. Auscultation revealed a continuous murmur at the left sternal border. The rest of the clinical examination and laboratory workup was unremarkable. Transthoracic echocardiography showed an anomalous vascular structure originating from the circumflex artery and draining to the main pulmonary artery with a significant left to right shunt, mild dilatation of the right heart chambers, and a 60% ejection fraction. Magnetic resonance imaging and coronary angiography confirmed the presence of a coronary artery fistula (Fig. 1). The pulmonary to systemic flow ratio was calculated as 1.8 to 1. Transcatheter closure was not feasible due to the absence of an appropriate neck and the patient was therefore referred for surgical correction.

Fig. 1

Coronary arteriography depicting (A) the fistula originating from the circumflex artery and (B) draining into the main pulmonary artery (arrows).

A left anterior mini-thoracotomy (5 cm) was performed and the thoracic cavity was entered via the third intercostal space. With the left lung deflated, the left phrenic nerve was identified; the pericardium was then incised and suspended to the margins of the incision. The exposure was excellent and the fistulous tracts were identified (Fig. 2A). The fistula on the pulmonary artery side was obliterated with multiple pledgeted 5-0 polypropylene sutures (Fig. 2B). Transesophageal echocardiography confirmed the successful closure of the fistula, the lack of a residual shunt, and the lack of wall motion abnormalities, while the electrocardiogram did not show any signs of ischemia. The patient was extubated one hour after the completion of the procedure in the intensive care unit and was then transferred to the general ward. She was discharged on the second postoperative day. At six and twelve months follow-up, she remained free of any cardiovascular symptoms, while echocardiography showed no residual flow. Moreover, an excellent cosmetic result was achieved.

Fig. 2

Intraoperative photo showing (A) the fistulous tract (arrows) and (B) multiple pledgeted 5-0 polypropylene sutures occluding the fistula on the pulmonary artery side (arrows).

DISCUSSION

A coronary artery fistula is a mostly congenital, abnormal communication between a coronary artery or its branches and another cardiovascular structure. Several variations have been described. Most commonly, it originates from the right coronary artery (60%) followed by the left coronary artery (35%). It usually drains into the right heart chambers: most commonly the right ventricle (40%), followed by the right atrium (25%), the pulmonary artery (15%–20%), and the coronary sinus (7%) [1]. It can also be acquired by iatrogenic and non-iatrogenic trauma, infectious diseases, as a result of transcutaneous catheter intervention, or as a clinical complication of Kawasaki disease [2]. These fistulae may increase in size and cause symptoms, heart failure, or potentially lethal complications. Current treatment includes surgical ligation alone or accompanied by coronary artery bypass grafting with or without cardiopulmonary bypass support, or, alternatively, transcatheter closure [2,3].

Although the surgical correction of coronary artery fistulae is a fairly common procedure, we believe our presented case is the first reported case of surgical ligation of a coronary fistula via a left anterior mini-thoracotomy. This approach, known as the Chamberlain procedure, is a well-established technique in thoracic surgery and offers a reliable method for obtaining a tissue diagnosis in anterosuperior mediastinal masses. In cardiac surgery, the typical left anterior thoracotomy has an established role in repeated mitral valve surgery [4-6], and its use for aortic valve replacement has also been described [7]. A left thoracotomy has also been used in mitral valve surgery as a minimal access approach and as an alternative for redoing cardiac surgery when a previous median sternotomy has been performed [8,9]. Its use has also recently been described for pulmonary valve replacement [6].

Using this approach in conjunction with double lumen tracheal intubation, an excellent surgical exposure of the anterior and left heart surface can be achieved. Although it was not necessary in our case, cardiovascular bypass could be established in this procedure. Although, it was not necessary in our case, cardiopulmonary bypass could be established through the aorta for arterial cannulation and the femoral vein for venous cannulation.

A left anterior mini-thoracotomy can provide an excellent surgical exposure for coronary artery fistula ligation in certain cases. It is a safe alternative with excellent cosmetic results and may minimize hospitalization time.