Results
Of the 13 cases, 10 (77%) had coronary artery-pulmonary artery fistula (CA-PA fistula) and two (15%) had coronary artery-coronary sinus fistula (CA-CS fistula) (Table 1). There was also one case (8%) with CA-PA fistula and one with CA-CS fistula. Seven patients (54%) had the following comorbid cardiovascular diseases: aortic stenosis, aortic regurgitation, mitral regurgitation, tricuspid regurgitation, ascending aortic dilatation, and patent foramen ovale. Pulmonary and systemic flow (Qp/Qs) was measured in seven cases (54%), and its average was 1.52 (Table 1). A majority of the CAFs with arterial origins were right coronary artery (RCA) or left coronary artery (LCA); however, they also originated from other regions, such as the aorta and left internal thoracic artery in a small number of cases. The majority of the coronary artery fistulas drained into the main pulmonary artery (Table 2). The formation of an aneurysm in abnormal blood vessels was found in three cases (23%), and one of these caused its rupture. Coronary sinus dilatation was observed in all cases with CA-CS fistula. Seven patients (54%) underwent surgery for CAFs alone, and others simultaneously underwent surgery for comorbid cardiac diseases.
Preoperative ECG findings were as follows: normal sinus rhythm (n=9, 69%), atrial fibrillation (n=2, 15%), multifocal supraventricular extrasystole (n=1, 8%), left atrial enlargement (n=1, 8%). Preoperative transthoracic echocardiography showed no asynergy in any of the cases and low EF(EF<50%) in four patients (30%). Myocardial scintigraphy was performed in two cases (15%), one of which showed small regional ischemia in the peripheral region of the RCA.
Operations were performed via median sternotomy and through the use of the cardiopulmonary bypass in all patients. The surgical procedure for CAFs was as follows: direct epicardial ligation of CAFs alone (n=6, 46%), direct epicardial ligation of CAFs plus direct closure of CAFs through pulmonary artery incision (n=5, 38%), direct closure of CAF through coronary sinus incision (n=1, 8%), patch closure of CAF through coronary artery incision (n=1, 8%) (Table 3). Concomitant procedures were Aortic Valve Replacement (AVR) (n=4, 15%), Mitral Valve Replacement (MVP) (n=2, 15%), Tricuspid Valve Annuloplasty (TAP) (n=2, 15%), and others (n=2, 15%).
There were no operative deaths and no significant ST-T change in ECG after surgery. One patient showed asymptomatic myocardial ischemia postoperatively. Moreover, poor contrast enhancement of RCA #2 on coronary CT for was found in routine postoperative examination (Figure 1). Myocardial perfusion scintigraphy showed mild regional ischemia. No ECG and TTE changes were observed in this case compared with preoperative data. The patient was asymptomatic and monitored with anticoagulation therapy.
The average postoperative follow-up period was 66.2 months (11-138 months) without any late deaths. During follow-up, one patient (8%) underwent thoracic aortic surgery (Bentall procedure and total arch replacement) two years after primary surgery. Another patient presented with paroxysmal atrial tachycardia nine years after surgery. There were no CAF-related events, including myocardial ischemia.