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.