Incidental left anterior descending coronary artery to pulmonary artery fistula in myxomatous mitral valve prolapse.

Uniqueness of this case report is that though coronary cameral fistulas are itself rare, we closed fistula effectively in a different way. Since surgery was only good option available as patient had concomitant valvular disease, we closed distal end of fistula in PA and then took deep bites of suture in fistulous track itself. This approach closed fistula effectively and we had no need to dissect and ligate its origin from LAD which is more arduous and dangerous task.

Case description

A 37-year-old male incidentally detected to have a murmur underwent transthoracic echocardiography (TTE) which showed myxomatous and thickened chordae and leaflets with prolapse of both leaflets into left atrium resulting in severe eccentric jet of mitral regurgitation. Left ventricular function was normal. LV diastolic dimensions were high normal. Coronary angiogram showed coronary fistula in mid LAD draining into pulmonary artery causing decreased flow in LAD distal to fistula (Fig. 1). Preoperative hemodynamic significance of fistula was not determined by cardiologist. In view of severe MR with increasing diastolic dimensions of LV, it was decided to operate the patient.

Fig. 1

Conventional coronary angiogram showing decreased flow in distal LAD after origin of coronary fistula.

Intraoperatively a large tortuous vessel was seen on anterior and lateral aspects of pulmonary artery (PA) (Fig. 2). Aorta was cross clamped and cardioplegic solution was started. Pulmonary artery was opened vertically. Entry point of coronary fistula in PA could be identified in form of a small opening above pulmonary valve from which cardioplegic solution was coming out. This opening was closed with prolene suture. After that PA was closed taking tortuous vessel in suture bites (Fig. 3). LA was then opened and mitral valve was found to be irreparable. So it was replaced with a bileaflet metallic prosthesis. Postcardiopulmonary bypass, right atrium and pulmonary artery saturations showed almost no gradient. The patient had an uneventful postoperative course.

Fig. 2

Intraoperative view of fistula. Tortuous tract of fistula seen over anterior surface of pulmonary artery.

Fig. 3

Postoperative view of completed repair. Deep suture bites were taken through fistulous tract while closing PA. Distal end of fistula was suture ligated from inside of PA.

Discussion

Fistula between coronary artery and pulmonary artery was first described by Krause in 1865, but first successful surgical treatment was described by Fell and colleagues in 1958.

Coronary artery fistula causes myocardial ischemia both by producing a coronary steal and by imposing an additional volume load on the left ventricle. However, most of these patients are entirely asymptomatic.1, 2

The fistula can be closed by transcatheter embolization or surgical intervention. This patient had LAD-PA fistula and mitral valve disease, and both conditions were surgically treatable. The main goal was to perform mitral valve surgery and closure of fistula in same procedure.

Conflicts of interest

The authors have none to declare.