Surgical Closure of Complex Congenital Arterial Venous Coronary Fistula

Introduction

Coronary fistulae are very rare anomalies found in only 1-2% of the population. However, within the spectrum of congenital coronary anomalies, termination anomalies are the most common after origin anomalies (e.g., anomalous coronary artery from the pulmonary artery and anomalous aortic origin of the coronaries). If untreated, patients develop heart failure because of a left to right shunt, myocardial ischemia secondary to a coronary steal phenomenon, and, rarely, endocarditis because of turbulent blood flow. Aneurismal rupture is rare. Currently, treatment is via transcatheter embolization. Fistulae with difficult anatomy, or associated with other cardiac defects that need correction, require surgery.

Case History

This video depicts the surgical correction of a complex congenital arterial venous coronary fistula in a 49-year-old male patient, who presented with a three-day history of palpitations and a continuous murmur. Subsequent investigations demonstrated a complex fistula between the right coronary artery, the mid circumflex, and the coronary sinus resulting in a venous aneurysm. The anatomy of the fistula precluded transcatheter closure, therefore the patient was listed for surgery. The surgery was performed on cardiopulmonary bypass. It entailed excision of the venous aneurysm, and closure of the fistulous communications using bovine pericardial patches. One year after the procedure, the patient has remained asymptomatic and has resumed exercising. His follow-up CT angiogram demonstrated a very small persistent fistula of no clinical significance that does not require further intervention.