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.     

Intraoperative ultrasonographic identification of coronary artery compression after an arterial switch procedure

A case is reported of a neonate with transposition of the great arteries, undergoing an arterial switch operation, in whom the cause for postbypass cardiac failure was diagnosed by intraoperative epicardial echocardiography. Obvious regional dyskinesia was seen by two-dimensional echocardiography in the posterolateral segments of the left ventricle, supplied by the circumflex coronary artery. After the switch procedure, the reimplanted circumflex artery ran between the aorta and the pulmonary artery. Lifting the pulmonary artery off the circumflex artery resulted in immediate improvement of regional myocardial function, which could be monitored on-line with echocardiography. Thus compression of the circumflex by the pulmonary artery was the cause for cardiac failure. On the basis of the echocardiographic information, immediate and successful surgical revision was performed. Intraoperative epicardial echocardiography has a unique diagnostic potential in the case of cardiac failure after cardiopulmonary bypass.     

Congenital coronary artery- cardiac chamber fistula. Review of operative management.

Eight patients who had surgical correction of coronary artery-cardiac chamber fistula at our center and 163 from a review of the literature are presented. The patients are usually asymptomatic, and the diagnosis is suspected by observing a continuous cardiac murmur. Electrocardiographic findings are nonspecific. Angina pectoris or electrocardiographic evidence of severe ischemia are surprisingly uncommon since coronary artery steal syndrome is also rare. Cardiac catheterization with angiocardiography is required to establish the diagnosis and identify the involved coronary artery and the cardiac chamber into which the fistula terminates. Left-to-right shunt flow is usually low (average Qp/Qs = 1.5). Indications for operation are not precise. If there should be a large shunt flow (2.0) and symptoms of heart failure are present, the decision to operate is clearly justified. This situation is unusual, and operation is nearly always performed in an asymptomatic patient in whom the fistula is closed to prevent future symptoms or complications. The operation chosen is generally interruption of the fistula by direct ligation. Sometimes cardiopulmonary bypass is required. The results are good, with low morbidity (3.6% myocardial infarction) and low mortality (2%) justifying the operation, to be carried out prophylactically even in asymptomatic patients.     

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 case of coronary arterial fistula orginating 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 developedstaphylococcus 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.     

Surgical Treatment of Coronary Artery-Pulmonary Artery Fistula with Coronary Artery Disease

Abstract   Coronary arteriovenous fistulae present rare clinical finding with the incidence of about 0.002% in the general population. Usually they are asymptomatic, but sometimes they can mimic other cardiac diseases, most commonly heart failure, myocardial ischemia, and endocarditis. Coronary arteriovenous fistulae have been reported to arise more commonly from the right coronary artery. Most of these fistulae are congenital, and only a small fraction acquired. In this report we present successful surgical treatment of coronary artery to pulmonary artery fistula combined with myocardial revascularization.     

肺动脉窦壁"L"形切口冠状动脉移植在大动脉调转术中的应用

目的 总结肺动脉窦壁"L"形切口行冠状动脉移植在大动脉调转术中的应用体会.方法 采用在肺动脉窦壁做"L"形切口的方法行大动脉调转术(ASO)治疗心室大动脉连接异常病儿25例,其中4例为快速两期ASO治疗,男16例,女9例;年龄6d～66个月;体重2.5～15.0 kg,平均(4.7±2.9)kg.完全性大动脉转位(D-TGA)19例,其中室间隔完整型(TGA-IVS)10例,室间隔缺损(TGA-VSD)9例;右室双出口伴肺动脉瓣下室间隔缺损(Taussig-Bing,TBA)6例.术中冠状动脉移植采用在相应邻近的肺动脉窦壁做"L"形切口,形成"门板状"活瓣的方法.结果 全组手术中开放升主动脉后心脏自动复跳,未发现心肌缺血的心电图和临床表现.术后早期循环均稳定.术后早期死亡4例,均与冠脉移植无明确关系.结论 采用"L"形切口进行冠脉移植,可以相对增加冠状动脉的长度,减少游离冠状动脉范围,减小张力,同时可以减轻冠状动脉移植后的扭曲.     

Internal mammary artery bypass after the arterial switch operation

Myocardial ischemia may ensure after coronary artery translocation during the arterial switch operation. We report the successful use of a right internal mammary artery to right coronary artery bypass graft in an infant with angiographic documentation of persistent graft patency 6 months postoperatively.     

Arterial switch operation: successful bilateral internal thoracic artery grafting

Internal thoracic artery grafting in arterial switch operations for transposition of great arteries has been reported for salvage of myocardial ischemia after initial coronary transfer. We report a situation where we opted for primary coronary bypass grafting to avoid an obviously difficult coronary transfer, with successful outcome.     

Surgical correction of congenital left coronary artery-main pulmonary artery fistula in association with anomalous right coronary artery.

The association of a left coronary artery-main pulmonary artery fistula and an anomalous right coronary artery originating from the main pulmonary artery is the subject of this report. This unique combination of congenital cardiac anomalies establishes a double coronary steal from the left coronary artery, which hemodynamically represents the sole source of myocardial perfusion. The left coronary artery-main pulmonary artery fistula was closed and the coexisting anomalous right coronary artery reimplanted into the anterior aspect of the ascencing aorta. A dual coronary supply was therefore established and thus eliminated the potential threat of total myocardial ischemia should the left coronary artery become critically compromised. Patency of both the left coronary artery and the transplanted right coronary artery was documented 1 year postoperatively by aortic root angiography.     

Determinants of cardiac failure after coronary bypass surgery within 30 days of acute myocardial infarction

Timing of coronary artery bypass grafting after acute myocardial infarction (MI) is controversial, especially if myocardial function is depressed. Early coronary artery bypass grafting may result in reperfusion injury causing cardiac failure. Delay, however, may risk a second ischemic event. This study was performed to determine if four preoperative factors--time after MI, ejection fraction, ischemia (need for intravenous administration of nitroglycerin), and failure (need for inotropic support)--independently predict postoperative cardiac failure. Postoperative failure was defined as the need for inotropic support or intraaortic balloon pumping. The study group consisted of 145 patients who underwent isolated coronary artery bypass grafting between January, 1980, and July, 1985, within 4 weeks of an acute MI. Postoperatively 38 patients (26%) had cardiac failure. Five patients, all of whom had postoperative cardiac failure, died. Univariate and stepwise logistic regression analyses showed preoperative failure (p = .0001), ejection fraction less than 45% (p = .002), and preoperative ischemia (p = .02) were predictors of postoperative cardiac failure. Time after MI was not found to be an independent predictor (p = .96). We conclude that if ischemia or threatening coronary anatomy is present early after MI and clinical improvement is not occurring, operative intervention should be strongly considered at that time, as it does not appear that delay itself reduces the risk of cardiac failure and may risk a second ischemic event.     

Recent progress in surgical treatment of congenital heart defects

Since Jatene's, Norwood's and Fontan's eras, recent striking progress in surgical treatment for patients with congenital heart defects has been achieved based on several advances, including 1) selecting an appropriate staged strategy for each phase of growth and development immediately after birth, 2) early complete and definitive repair, and 3) noninvasive diagnoses and surgical treatment, all of which lead to good ventricular function and exercise tolerance later in life. General cardiopulmonary bypass and support techniques have been improved to prevent the systemic inflammatory response syndrome with capillary leakage. Washing blood primes, diluted ultrafiltration, and modified ultrafiltration are routinely performed. The arterial switch operation is one of the greatest achievements in neonatal cardiac surgery during the past three decades. The most crucial step in arterial switch is related to coronary mobilization and transfer without myocardial ischemia. The specific issue in the Norwood operation for hypoplastic left heart syndrome is the regulation of pulmonary blood flow. Right ventricle-pulmonary artery shunt in the Norwood operation provides stable systemic circulation and adequate pulmonary blood flow without delicate postoperative management to control pulmonary vascular resistance. Cerebral and lower systemic dual perfusion is very useful for arch repair in early infancy. Complete repair of tetralogy of Fallot around six months of age has shown satisfactory results.     

Right coronary artery fistula draining into the right atrium and associated with mitral valve stenosis: a case report

Coronary artery fistula (CAF) is a rare congenital anomaly of the coronary arteries in which abnormal connections are present between the coronary artery branch and the cardiac chambers or a major vessel. The incidence of CAF is estimated at 1 in 50,000 live births, and it is detected in approximately 0.2% of the adult population during coronary angiography. Reports of the coincidence of mitral stenosis and CAF are rare in the literature. We report a case of CAF and mitral valve stenosis in a patient with dyspnea and fatigue before valve replacement and surgical radiofrequency ablation. Coronary angiography showed a connection between the right coronary artery and right atrium. A fistula opening into the right atrium is rare in patients with coronary artery anomalies and mitral valve disease. Coronary angiography of the patient 1 month after surgical repair showed that the coronary anatomy was normal and the fistula was occluded. CAF can be diagnosed more frequently if coronary angiography is performed simultaneously with cardiac catheterization to evaluate valve functions or nonatherosclerotic myocardial ischemia in each valvular heart disease case. Surgical repair of CAF is the first-choice treatment to prevent complications and improve quality of life.     

Surgical treatment of coronary artery-pulmonary artery fistula with coronary aneurysm]

We experienced 4 cases of coronary artery-pulmonary artery fistula with coronary aneurysm, three patients had symptoms of chest pain, and 1 patient had cardiac murmur. Coronary arteriography showed that three patients had fistulas from the left coronary artery to the pulmonary artery; and that 1 patient had a fistula from both the right and left coronary arteries to the pulmonary artery. Moreover, 1 patient had 90% diameter stenosis of segment 7. The maximum diameter of the coronary aneurysm ranged from 12 to 20 mm (average: 15.3 mm). One patient underwent closure of the opening of the fistula, 2 patients underwent multiple ligatures of fistulas, and 1 patient underwent multiple ligatures of fistulas with coronary artery bypass grafting. The postoperative course of every patient was uneventful. There have been 42 reports on this abnormality in Japan. We should treat the fistula as early as possible to prevent cardiac complications such as myocardial ischemia and rupture of coronary aneurysm.     

Coronary cameral fistula from the sinoatrial nodal artery to the right atrium

Coronary artery fistula is a connection between coronary artery and its branch to any of the cardiac chamber, great vessel or coronary sinus bypassing the myocardial capillary bed. Majority of fistulas are congenital in origin, although acquired fistulas may be encountered occasionally after cardiac surgery, endocarditis and after repeated myocardial biopsies (Somers and Verney, Clin Radioly 44:419–421, 1991). We report a 55-year-old female patient of large coronary cameral fistula between sinoatrial nodal artery and right atrium. She presented with congestive heart failure, atrial fibrillation and deterioration of left ventricular function with mitral regurgitation with functional class 3. The patient was managed with closure of origin of fistula from inside the aorta using polytetrafluoroethylene (PTFE) patch of 1.5?×?1.5 cm, on cardiopulmonary bypass using blood cardioplegia, as rest of the right coronary artery (RCA) was rudimentary. She had uneventful recovery with improvement in the functional class 1.     

Active distal coronary perfusion to prevent regional myocardial ischemia in off-pump coronary artery bypass grafting.

Regional myocardial ischemia during anastomosis in off-pump coronary artery bypass (OPCAB) can occasionally cause hemodynamic instability. To prevent regional myocardial ischemia and stabilize the hemodynamics during the procedure, perfusion of the distal coronary artery to the anastomotic site is necessary as the only reliable method. We have applied an active coronary perfusion method using a servo-controlled pump in selected patients in place of conventional passive perfusion methods (intraluminal shunt and external shunt). We present a case in which the active perfusion method proved useful in avoiding regional myocardial ischemia. A 74-year-old male patient with triple-vessel coronary disease underwent OPCAB for unstable angina. During revascularization of the main right coronary artery, the hemodynamics collapsed due to regional myocardial ischemia. As soon as the distal coronary artery was perfused at a high flow rate around 80 ml/min, the hemodynamics stabilized and the operation was completed successfully. This active coronary perfusion method in OPCAB is particularly useful in cases in which regional myocardial ischemia cause hemodynamic instability.     

Arterial Switch Operation with Coronary Arteries from a Single Sinus in Infants

Abstract Background: The implantation of a coronary artery (CA) is critical for the arterial switch operation (ASO) done to treat complete transposition of the great arteries (TGA). Coronary artery abnormalities are risk factors for both early and late mortality after surgery. In this study, the methodology and effects of ASO surgery with coronary arteries from a single sinus were evaluated. Methods and Results: From March 1999 to June 2006, 31 patients were treated with ASO with coronary arteries from a single sinus in our hospital. They aged 11 hours ? 16 months (2.8 ± 3.9 months) and weighted 2.3 ?7.8Kg (3.1 ± 2.5Kg). 27 cases had TGA and a ventricular septal defect (VSD), and 4 had TGA and an intact ventricular septum (IVS). During surgery, a CA button was implanted in the new proximal aorta with “trapdoor” technique or by inverting 90 degrees dorsally; pericardium or arterial augmentation was implanted at the base of the new major artery. The mortality rate after surgery was 25.8%. After 2‐5 years of follow‐up, 2 cases with residual shunting recovered spontaneously, 2 cases had residual pulmonary artery obstruction (30‐56 mmHg), and none of the patients had any significant changes in myocardial ischemia. Conclusion: The implantation of an abnormal coronary artery is practical and feasible; it can reduce both the occurrence of twisting and deforming in the coronary artery after implantation, as well as myocardial ischemia after surgery. Thus, this could improve the surgical success and cure rates.     

急性肺栓塞时心肌血流灌注的变化

目的观察急性肺栓塞（APE）后冠状动脉血流量及心脏肌钙蛋白T（cTnT）与肌红蛋白（Mb）含量变化，探讨心肌血流灌注在急性肺栓塞继发心肌损伤机制中的作用。方法通过介入方法经导管注入自体血栓选择性栓塞肺动脉，建立不同栓塞面积的急性肺栓塞动物模型。监测栓前、栓后5、30min，1、2h冠状动脉血流量变化及栓后4h血清cTnT与Mb含量。结果急性肺栓塞后血清cTnT与Mb含量升高。急性肺栓塞导致冠状动脉血流量显著下降，肺血管栓塞后15～30min降至最低值，30min后趋于平稳。右冠血流量下降程度与肺栓塞面积有显著相关性。结论冠状动脉血流量减少及血清心肌结构蛋白含量升高为急性肺栓塞继发心肌缺血改变提供了直接证据。急性心肌缺血严重影响急性肺栓塞的预后。     

Vascular access in patients with arterial insufficiency. Construction of proximal bridge fistulae based on inflow from axillary branch arteries.

Patients with renal failure and underlying peripheral vascular disease pose a difficult management problem in establishing long-term angioaccess for chronic hemodialysis. This report summarizes our experience with five debilitated patients who developed acute upper extremity ischemia after forearm fistula construction corrected by fistula ligation. Successful angioaccess was achieved without ischemia recurrence by construction of proximal bridge fistulae with arterial inflow based on branch arteries of the axillary artery. The relatively small size of the branch vessel was the main factor in limiting fistula flow while permitting normal distal axillary artery flow. In four patients direct fistula flow measurements ranged from 200 mL per minute to 620 mL per minute. Axillary arterial flow distal to the fistula ranged from 120 to 200 mL per minute and did not significantly change after fistula construction or during temporary occlusion of the fistula. Four of the five patients continue to dialyze uneventfully from 4 to 8.5 months. One patient died after discontinuation of dialysis 1 month after operation.