Coronary artery to pulmonary artery fistula with dual origin--embryological, clinical and surgical significance.

Coronary artery fistulae are rare anomalies encountered in 0.1-0.2% of angiographic series. We recently encountered a patient evaluated for mitral valve disease who incidentally had bilateral coronary artery fistulae detected on preoperative angiogram. These fistulae drained into the pulmonary artery. She underwent successful transpulmonary closure of the fistula along with mitral valve repair. We discuss the embryological basis of this anomaly and the clinical as well as surgical significance.     

Coronary artery fistula; coronary computed topography – The diagnostic modality of choice

Coronary artery fistulae (CAF) are rare anomalies. They are vascular communications between the coronary arteries and other cardiac structures, either cardiac chambers or great vessels. There can be considerable variation in the course of a coronary artery fistula. We report a case of a coronary artery fistula between the left circumflex coronary artery and the right and left atria. CAF are often diagnosed by coronary angiogram, however with the advent of new technologies such as Coronary Computed Tomography Angiography (Coronary CTA) the course and communications of these fistulae can be delineated non-invasively and with greater accuracy.     

Coronary Artery Fistula Associated with Mitral Valve Endocarditis

Abstract Coronary artery fistulas are rare, and the further development of mitral valvular insufficiency and endocarditis is even more uncommon. We report a case of endocarditis secondary to a congenital coronary artery fistula arising from the right coronary artery and draining into the left ventricle. Vegetations were found on the mitral valve leaflet. The fistula was successfully treated with surgery, and the endocarditis, with antibiotic therapy. Surgical repair is the optimal treatment for coronary artery fistula, even in asymptomatic patients. (J Card Surg 2012;27:714‐715)     

Mitral valve repair, tricuspid valve annuloplasty, and ligation of coronary artery-pulmonary trunk fistula in a patient with arrhythmogenic right ventricular cardiomyopathy

Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a rare cardiac disorder characterized by replacement of myocytes with adipose and fibrous tissue and often presents with ventricular arrhythmia, heart failure, and sudden death. This report describes a 67-year-old man with ARVC complicated with severe mitral regurgitation, dilated annulus of the tricuspid valve, and coronary artery-pulmonary artery fistula. Mitral valve repair, tricuspid valve annuloplasty, and ligation of the coronary artery-pulmonary artery fistula were performed. The postoperative course was uneventful, and the patient was discharged on postoperative day 15.     

Left circumflex coronary artery to left atrial fistula in a patient with mitral regurgitation after excision of a left atrial myxoma.

Acquired coronary artery to left atrial fistulas are rare and previously only described in mitral stenosis associated with left atrial thrombus or coronary arteriosclerosis. We present the case of a patient who developed a left circumflex coronary artery to left atrial fistula associated with mitral regurgitation 12 years after excision of a left atrial myxoma. This was successfully ligated at the time of mitral valve replacement.     

A case of mitral stenosis associated with cardiac sarcoidosis and left ventricular aneurysm

We report a rare case of mitral stenosis associated with cardiac sarcoidosis and left ventricular aneurysm. A 60-year-old female was admitted with complaint of palpitation and dyspnea on exertion. Chest X-ray revealed cardiomegaly and pericardial calcification, but no bilateral hilar lymphadenopathy. Electrocardiogram showed various arrhythmia. Coronary angiography showed no stenosis in any coronary arteries. Cardioangiogram showed left ventricular aneurysm at the apex and mitral stenosis. Laboratory findings showed no evidence of sarcoidosis. Open mitral commissurotomy and left ventricular aneurysmectomy was performed. Pathological findings of the myocardium showed a remarkable degenerative change and a granulomatous inflammation. Postoperative biopsied specimens of right scalene lymph nodes revealed sarcoid reaction. The postoperative course was satisfactory, but arrhythmia remained. The patient was treated with steroids and pacemaker implantation. She has been doing well for 2 year postoperatively. An operative case of mitral stenosis associated with cardiac sarcoidosis and ventricular aneurysm due to sarcoidosis is very rare and the prognosis in patient is very poor usually.     

Iatrogenic left main and proximal right coronary artery stenoses after aortic valve replacement.

Iatrogenic left main coronary artery stenosis after aortic valve replacement is an infrequent but potentially life-threatening complication. A 44-year-old woman who had normal coronary arteries documented by preoperative coronary angiogram, and who developed severe stenosis of the left main coronary artery and subtotal occlusion of the proximal right coronary artery after aortic and mitral valve replacements is presented. Coronary lesions were clinically manifested 4 months after the first operation. Accurate diagnosis was confirmed by repeat coronary angiography. She underwent successful coronary artery bypass grafting.     

Anomalous left coronary from the pulmonary artery-clinical profile,operative techniques and patient outcomes

Background Anomalous left coronary artery arising from the pulmonary artery is a rare congenital heart disease. Mortality is in excess of 90% if left untreated during the first year of life. Surgical management has evolved from coronary ligation to anatomical repair by coronary button translocation to the aorta. We report our recent experience with surgical correction of this rare condition. Methods We retrospectively studied the case records of 14 consecutive patients operated in our institute between Jan 1998 to Aug 2004. The mean age was 65 months ±114 (Range 1 to 420). The male to female ratio was 2.5:1. Coronary ligation ws performed in two patients, coronary artery bypass grafting with saphenous vein graft was done in three, the last nine patients underwent coronary button transfer, one patient required concomitant mitral valve replacement. Clinical profile, surgical techniques and operative outcomes as well as long-term results were analyzed. Results Hospital mortality was 28.5% (4/14), Follow up was 100% complete with no late mortality, ranging from 1 months to five years. Ischaemic mitral regurgitation progressed in only one patient, remained the same in one and improved in all the others. All patients except one are in functional class I at last follow up. Conclusion In conclusion, infants presenting with a diagnosis of anomalous left coronary artery arising from pulmonary artery with congestive cardiac failure are a difficult subgroup of patients. Coronary button translocation has emerged as the single most effective surgical modality and is associated with good long-term results.     

Aortic dissection complicated with aorto-right atrium fistula.

Aorto-right atrium fistula associated with aortic dissection is a very rare complication. Here report a case of successful surgical repair of ascending aortic dissection complicated with aorto-right atrium fistula. A 65-year-old man was presented with sudden chest pain and dyspnea. Fifteen years ago, he had aortic valve replacement. An aortic dissection with fistula to the right atrium was diagnosed by echocardiography and cardiac catheterization. At operation, dense adhesion of the aortic root due to the previous cardiac operation was confirmed, and this was suggested as the cause for this rare complication.     

Mitral valve repair with concomitant coronary bypass for partial rupture of an anterior papillary muscle

We report a case of severe mitral regurgitation due to partial rupture of an anterior papillary muscle. A 63-year-old man was admitted to a hospital with heart failure. He was treated with diuretic agents effectively. Echocardiography demonstrated severe mitral regurgitation with prolapse of posterior leaflet and small mass-like structure on the prolapsed segment that was diagnosed the thickened leaflet. Coronary angiography revealed total occlusion of left anterior descending artery (LAD) filled with good collateral from right posterior descending artery and severe diffuse stenosis of circumflex artery (Cx). The patient underwent surgery on the 33rd day after admission with heart failure. At surgery, we recognized rupture of one of the heads of anterior papillary muscle that was entangled in chordae of the prolapsed segment. Mitral valve repair and coronary revascularization to LAD and Cx was successfully performed. His postoperative course was uneventful, and he was discharged on the 28th postoperative day.     

Combined Procedure of Coronary Artery Bypass Grafting and Valve Repair

The safety of combined operative procedures for valvular and coronary artery disease was reviewed in 27 patients. Twelve patients had aortic valve disease and 15 had mitral valve disease. Forty-seven coronary artery reconstructions were performed, an average of 1.7 per patient. Twenty-two patients underwent valve replacement and 5 had valvuloplasty. Congestive heart failure was the major symptom in 20 patients, and angina was the major symptom in 7. Eight of the patients with congestive heart failure had no angina, but significant coronary stenoses were demonstrated at routine coronary angiography.Coronary reconstruction was performed before valve repair. Two patients died postoperatively (a hospital mortality of 7.4%), and there were 4 late deaths from 2 to 28 months postoperatively. There were no postoperative myocardial infarctions.Contrary to previous reports, coronary artery reconstruction and valve repair need not be associated with an increased risk. Protection of the myocardium by coronary perfusion through reconstructed coronary arteries enables valve repair to be done without greater risk than valve repair alone. All patients considered for valve repair should have coronary angiography.     

Beating heart surgery for ischemic mitral regurgitation: report of a case

A 51-year-old man was admitted to our hospital because of dyspnea. Coronary angiography revealed triple vessel disease and echocardiography demonstrated severe mitral regurgitation with poor left ventricular function. Under a diagnosis of ischemic mitral regurgitation, on-pump beating mitral annuloplasty and coronary artery bypass grafting using the normothermic retrograde continuous coronary sinus perfusion of oxygenated blood was performed in order to prevent reperfusion injury. The patient was easily weaned from cardiopulmonary bypass and his postoperative course was uneventful. Because of the advantages of this procedure (e.g., no reperfusion injury, testing of the mitral valve repair is done in real physiologic conditions with beating tonus), on-pump beating heart surgery seems a good surgical option for ischemic mitral regurgitation with poor left ventricular function.     

A case of coronary arterial fistula originating from both coronary artery and draining to the right atrium]

We encountered a case with bilateral fistulas of coronary arteries into the right atrium, a rare cardiac anomaly. The case was a 17-year-old woman, who visited our hospital at the age of 11 because of fever. At that time, the patient was diagnosed as having a left coronary artery-right atrial fistula through cardiac catheterization (CAG). When the patient developed staphylococcus infected endocarditis at the age of 16, a thick fistula of the coronary artery, directly running from the deformed left coronary arterial sinus, a fistula of the left circumflex branch, and also a fistula of the right coronary artery into the right atrium were detected by CAG. The outlets of these fistulas were closed from the inside of the right atrium under artificial cardiopulmonary circulation and cardiac arrest, and each fistula was ligated at the outside of cardiac chambers. At that time, we took particular care that any branch of the sinuatrial node was not injured. Although all fistulas were confirmed to be closed by postoperative CAG, and no evidence of ischemia was detected by myocardial scintigraphy, deformity of the left coronary arterial sinus remained, requiring further follow up.     

A reoperation of adult-Type Bland-White-Garland syndrome

We present a 25-year-old female patient with Bland-White-Garland syndrome (anomalous origin of the left coronary artery from the pulmonary artery) who underwent mitral valve replacement (MVR) and coronary artery bypass grafting. She had previously undergone MVR and had been treated by the Takeuchi procedure for mitral valve regurgitation and a coronary artery anomaly, respectively, at 17 years of age. She was hospitalized with shortness of breath within 7 years of surgical intervention. Swan-Ganz catheterization revealed mild pulmonary hypertension and elevated mean pulmonary wedge pressure. Echocardiography revealed marked severe calcification of the bio valve and moderate mitral valve regurgitation. Coronary angiography revealed retrograde collateral blood flow from the right coronary artery to the left coronary artery, but intrapulmonary tunnel was not visualized by pulmonary arteriography. We performed MVR with a mechanical valve and coronary artery bypass grafting between the left internal thoracic artery and the left anterior descending artery. The postoperative course was unremarkable, and no complaints were reported during follow-up at the outpatient clinic.     

Left atrial myxoma with neovascularization presenting as a sick sinus syndrome

Myxoma is benign tumor of the heart. It is mostly located in the left atrium and revascularized by the left and right coronary artery in 30% to 40% of cases. Symptoms of these neovascularized cardiac myxomas are typically quite variable, from obstruction of mitral valve to coronary embolism resulting in acute myocardial infarction. In this case, left atrial myxoma that is revascularized by nodal branches of the right coronary artery presented as a sick sinus syndrome, which is rare in literature.     

Anomalous left coronary artery from pulmonary artery (ALCAPA) repair and mitral valve replacement with bioprosthetic valve with in a 62 year old lady

Anomalous Left Coronary Artery from Pulmonary Artery (ALCAPA) is the commonest congenital anomaly involving coronary arteries. The combination of this anomaly with mitral regurgitation is very rare in adult population. We report the case of a 62?year old lady, who presented with breathlessness and was found to have this combined anomaly. She was treated successfully with closure of left coronary ostium from pulmonary artery and mitral valve replacement with Hancock 2 Porcine valve. To our knowledge, this is the oldest patient to have undergone successful ALCAPA repair with mitral valve replacement with bioprosthetic valve.     

Extracardiac Right Atrium-to-Right Ventricle Homograft for Uncorrectable Tricuspid Valve Disease

Surgically uncorrectable tricuspid valve disease in children is rare. However, when it happens the surgical options are very limited. Tricuspid valve replacement using a mechanical valve or stented bioprosthesis is impractical. Use of homografts in the “anatomic position” has its limitations. We report here the use of an extracardiac homograft connection between the right atrium and right ventricle in a 16-month-old boy in whom severe tricuspid valve stenosis developed after surgical repair of a complex ventricular septal defect associated with dextrocardia and anomalous systemic venous drainage. The patient remains well receiving no cardiac medication 12 months after the procedure.     

Combined coronary artery bypass, mitral valve plasty, and abdominal aneurysmectomy in an 80-year-old patient: Report of a case

An 80-year-old man suffering from angina on exertion due to stenosis of the left main coronary artery, heart failure due to mitral valve regurgitation, and an abdominal aortic aneurysm (AAA) was successfully operated on with simultaneous surgical procedures. A coronary cineangiography revealed 90% stenosis of the left main coronary artery in segment 5, and 99% and 90% stenosis in segments 2 and 4AV, respectively, of the right coronary artery. Left ventriculography and aortography showed moderate mitral valve regurgitation and the presence of a fusiform-shaped AAA with a maximum diameter of 6 cm. It was thought that insertion of an intraaortic balloon pump (IABP) would prove difficult due to AAA; therefore, simultaneous surgery combining triple coronary artery bypass grafting (CABG), mitral valve plasty, and prosthetic replacement of the AAA was undertaken. The patient's postoperative course was uneventful, and subsequent angiography showed good patency of all coronary bypass grafts and the abdominal prosthesis, along with the disappearance of mitral regurgitation. This patient's clinical course suggests that an extended surgical procedure is effective for the treatment of complicated cardiovascular disease, even in very elderly patients.     

Successful surgical treatment of rupture of coronary arteriovenous fistula with unconsciousness after chest and back pain.

A 65 year-old woman was admitted to our hospital, because of unconsciousness after chest and back pain. Echocardiography showed pericardial effusion. She suffered from pre-shock due to cardiac tamponade. Although a cause of cardiac tamponade was unclear, we performed emergency surgical treatment without coronary angiography. In operation, we found a rupture of coronary arteriovenous fistula and repaired it. The patient recovered from the surgery uneventfully. Coronary artery fistula is an abnormal communication between a coronary artery and a cardiac chamber or major vessel. It is the most common congenital anomalies of the coronary arteries. Many patients with these anomalies remain asymptomatic, but some patients develop symptoms of congestive heart failure, infective endocarditis, myocardial ischemia, arrhythmia, or rupture of an aneurismal fistula. Usually, the dilatation of fistula is common, and although 19% of this may become aneurysmal, the rupture of the aneurysm is very rare. We report a case of ruptured coronary arteriovenous fistula who underwent successful emergent surgery.     

Large common left and right coronary artery to coronary sinus fistula

Coronary fistulas are vascular anomalies which in rare cases can cause hemodynamic problems with indication for intervention. We report about a 47-year-old man with a large coronary fistula arising from both, the left and right coronary artery. To our knowledge this is the first case described with this anatomy. The main coronary arteries were united at the crux cordis and drained through the coronary sinus into the right atrium. As a consequence of the longstanding volume overload the coronary arteries were extremely dilated. Also, both ventricles were dilated. Therefore, although the patient was asymptomatic, the obvious compromise of the ventricles due to volume overload was regarded as an indication for surgical intervention.