Challenging surgery of giant right coronary aneurysm associated with coronary sinus fistula

Coronary artery fistula is a rare congenital or acquired anomaly. It involves an abnormal connection between the coronary artery and the cardiac chambers or the large thoracic vessels. In some cases, the feeding coronary artery can become extremely dilated. The treatment includes a transcatheter or a surgical intervention depending on the complexity of the anomaly. We present the surgical treatment of the coronary artery to coronary sinus fistula, which includes the complete exclusion of the giant right coronary artery and followed by triple bypass surgery.     

Successful surgical management for aneurysms of single coronary artery with a fistulous connection to the right ventricle

While a coronary artery fistula with aneurysmal formation is rare, a fistula/aneurysm combination occurring in single coronary artery is even rarer. Here, we report the successful surgical correction of a right ventricular fistula with a large aneurysm of 30 mm and a daughter aneurysm within a case of single coronary artery.     

Double right coronary artery; fistula and atherosclerosis

Combination of the primary congenital coronary artery anomalies, fistula and atherosclerosis rarely occur. We report a 50-year-old male who presented with severe chest pain, for which he underwent a coronary angiography. Injection into the right coronary artery (RCA) demonstrated a double RCA running very closely together in the atrioventricular groove. The superior one gave rise to a coronary fistula leading to the right ventricle and the inferior one was atherosclerotic. Both of them terminated as a posterior descending artery. The left system showed occlusion of the left anterior descending and major obtuse marginal. Both were corrected surgically.     

Tortuous right coronary artery to coronary sinus fistula

We are reporting the successful surgical treatment of a 23-year-old female with a giant right coronary artery to coronary sinus fistula. This woman had complaints of chest pain and dyspnea on exertion for few months. Transthoracic echocardiography (TTE) showed a large tortuous right coronary artery and a dilated coronary sinus. Preoperative multi-detector computed tomography (MDCT) coronary angiography and cardiac catheterization confirmed the diagnosis of a right coronary artery to coronary sinus fistula. The patient underwent surgical closure of the fistula and division of the communication between the right coronary artery and the coronary sinus with the use of cardiopulmonary bypass. The patient was discharged home on postoperative day 5 and at one-year follow-up is symptom-free.     

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.     

法洛四联症伴冠状动脉畸形的外科治疗

目的：总结法洛四联症伴冠状动脉畸形手术治疗经验,探讨冠状动脉畸形在法洛四联症纠治手术中的意义。方法：自1994年1月至1999年12月,手术治疗法洛四联症伴冠状动脉畸形15例,年龄43d-8岁,其中右冠状动脉起源于左冠状动脉或左前降支6例,单支左冠状动脉和左前降支起源于右冠状动脉各3例。双前降支,单支右冠状动脉和右冠状动脉肺动脉瘘各1例。一期根治手术13例,姑息手术2例。结果：姑息手术无死亡,根治手术早期死亡1例;无冠状动脉手术意外损伤;随访结果满意。结论：根据肺血管条件和畸形冠状动脉走行特点,选择适当的手术方式和右室流出道重建方法可提高手术效果;冠状动脉畸形不再是法洛四联症纠治手术中的风险因素。     

Single left coronary artery with a fistula to the right ventricle: report of a case with successful closure

A 4-year-old boy of single left coronary artery associated with a fistula to the right ventricle was reported. Cardiac catheterization and selective coronary angiography revealed single left coronary artery with a fistula to the right ventricle. At operation, a single coronary artery arising from the left aortic sinus was present. A dilated and tortuous left circumflex branch passed to the right and anterior . This vessel terminated into the outflow tract of the right ventricle. The dilated vessel was doubly ligated at just distal portion of a acute marginal branch. The fistula to the right ventricle was directly sutured from arteriotomy. Then three small branches from the anterior descending artery terminating into the terminal portion of the dilated vessel were found and these were ligated respectively. After repair of arteriotomy, the remainder of the dilated and tortuous vessel was wrapped with a Dacron mesh for reinforcement. Postoperative course was uneventful and there were no complications.     

Tetralogy of Fallot correction with transannular patch reconstruction in a patient with an anomalous right coronary artery and an unusual course of the right ventricular branch

Anomalous coronary arteries occur in as many as 12% of patients with tetralogy of Fallot (TOF). In patients with this condition, pulmonary hypoplasia can be prohibitive in performing a valve-sparing repair, subsequently resulting in various techniques to preserve the anomalous coronary artery. The management strategy is often complex in such a situation. We report on a case of TOF with an anomalous right coronary artery crossing the right ventricular outflow tract, with an unusual course of the right ventricular (RV) branch, which precluded placement of a valved conduit. In this case, we performed a successful repair with mobilization of the anomalous coronary artery and reconstruction of the right ventricular outflow tract with a limited transannular patch.     

Ligation of a fistula between the left main coronary artery and both the pulmonary artery and the right ventricle

The frequency of coronary artery fistula among all coronary angiography patients is 0.1% to 0.2%; however, involvement of both the pulmonary artery and the right ventricle is a rare clinical entity. A 53-year-old man patient was admitted to our clinic with rarely occurring chest pain, palpitations, and dyspnea. A coronary angiogram showed a fistula between the left main coronary artery and both the pulmonary artery and the right ventricle. We performed a ligation of this fistula without cardiopulmonary bypass. Aorta and right ventricle sutures were made, and the proximal and distal portions of the fistula were obliterated with 5-0 Prolene sutures and previously prepared Teflon felt. The patient recovered and was discharged without any complications. The surgical indications for coronary artery fistulas are symptomatic disease, an aneurysmic coronary artery, signs of heart failure, and ischemia. The surgical options in such cases--depending on whether the fistula is complicated or not--are simple ligation or transarterial ligation under cardiopulmonary bypass.     

Ross procedure for congenital aortic insufficiency and an associated right intramural coronary artery

A 7-year-old boy diagnosed with aortic insufficiency was treated with a Ross procedure and he had an associated right intramural coronary artery. Although preoperative angiocardiography showed that the right and left coronary artery orifices were close together, a right intramural coronary artery could not be diagnosed by transthoracic echocardiography. Intraoperative findings showed that the right coronary artery was intramural for a distance of 7 mm. As a result, a longer single coronary button was harvested and transplanted to the pulmonary autograft. The postoperative course was uneventful; coronary ischemia did not occur and aortic valve function was preserved.     

Grafting an anomalous coronary artery: a left anterior descending from the right coronary artery grafted with the right internal thoracic artery

A left anterior descending artery (LAD) arising from the right coronary artery (RCA) or right sinus of Valsalva is an exceedingly rare anomalous variant occurring in 0.03% of the population. We here present the case of an 81-year-old male with severe triple vessel coronary artery disease who was found to have an aberrant LAD arising from the proximal RCA, and was successfully treated with off-pump, total arterial, and complete surgical revascularization.     

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.     

Primary cardiac angiosarcoma resection combined with right coronary artery bypass grafting

A 41-year-old woman presented with symptoms of cardiac tamponade. Diagnosis of a primary malignant tumor in the right atrium without distant metastasis was made by echocardiography, computed tomography and coronary angiography. Aggressive surgery consisting of resection of the tumor including the right atrial wall together with the right coronary artery and sinus node was performed. This was followed by coronary artery bypass grafting with myocardial electrode implantation for reconstruction of the right atrial wall using an equine pericardium. Final diagnosis was of angiosarcoma by pathological examination. Consequently, the patient underwent additional radiotherapy and was discharged. She is currently in good health with no recurrence 1.5 years after surgery.     

Successful surgical treatment of a mycotic right coronary artery aneurysm complicated by a fistula to the right atrium

We reported successful surgical treatment of a mycotic right coronary artery aneurysm complicated by a fistula to the right atrium in a 60-year-old man admitted to hospital because of acute worsening of renal function and erythroderma. After admission, he suffered from methicillin-resistantStaphylococcus aureus septicemia. Despite administration of vancomycin hydrochloride, a low-grade fever persisted. Subacute cardiac tamponade occurred three months after admission, and acute inferior wall myocardial infarction occurred two weeks after pericardial drainage. An emergent coronary angiography demonstrated a large saccular aneurysm of the right coronary artery forming a fistula to the right atrium and obstruction of the distal right coronary artery. We emergently resected the aneurysm including the right atrial wall and repaired the defect in the right atrium. Pathological examination of the aneurysmal wall revealed its mycotic nature; the postoperative course was uneventful. (Jpn J Thorac Cardiovasc Surg 2005; 53: 661–664)     

Cephalic pancreaticoduodenectomy with preservation of a right coronary artery bypass graft using the right gastro-epiploic artery: a case report

Introduction: Pancreatic cancer is a rare disease with a high mortality rate, for which complete surgical resection, when possible, is the preferred therapeutic. Pancreaticoduodenectomy represents the surgical technique of choice. Abdominal surgeons can be faced with the challenge of patients with a history of coronary artery bypass graft in which the right gastro-epiploic artery is used.

Case report: We report the case of a patient with an adenocarcinoma of the pancreatic head, stage IIA, having previously undergone a triple coronary artery bypass, one of which being a right gastro-epiploic graft. Our challenge was underlined by the necessity of a complete oncological resection through a cephalic pancreaticoduodenectomy while preserving the necessary cardiac perfusion via the right gastro-epiploic artery.

Conclusion: We have been able to preserve a right gastro-epiploic artery as a coronary bypass during a cephalic pancreaticoduodenectomy for a cephalic pancreatic adenocarcinoma. We have successfully been able to preserve and re-implant the right gastro-epiploic artery to the origin of the gastroduodenal artery while insuring R0 resection of the tumor. A coronary artery bypass using the right gastro-epiploic artery should therefore not be considered as an obstacle to a Whipple’s procedure if total oncological resection is obtainable.     

Coronary artery fistula into a persistent left superior vena cava: Report of a case

We herein report the rare case of a patient with coronary artery fistula (CAF) between the left circumflex coronary artery and persistent left superior vena cava (PLSVC) with a complete absence of the right superior vena cava (SVC).     

Giant aneurysm of the right coronary artery and fistula to the coronary sinus

We describe the case of a 67-year-old man with a rare combination of a giant coronary artery aneurysm with a fistula draining into the coronary sinus. The patient presented with a sensation of retrosternal pressure. He was examined by coronary angiography, which revealed a large aneurysm of the right coronary artery (RCA) with a fistula. This fistula originated from the distal RCA shortly beyond the crux and drained into the coronary sinus. The aneurysm was in the proximal portion of the RCA, measuring 4 cm in diameter and 7 cm in length. Surgical repair by closure of the fistula under direct vision, suture closure and plication of the aneurysm, and coronary artery bypass was performed. Postoperative echocardiography and computed tomography confirmed closure of the fistula. The patient remains symptom-free at 4 months after surgery.     

Large saphenous vein graft aneurysm with a fistula to the right atrium.

We report on a case of a 65-year-old man who was admitted for anterior chest pain on effort. He had received coronary artery bypass grafting (CABG) surgery 20 years ago with saphenous vein grafts (SVGs) to the left anterior descending artery (LAD) and right coronary artery (RCA). An angiography demonstrated large aneurysmal dilatation of both grafts and a fistulous communication between the middle portion of the right SVG and the right atrium (RA). The aneurysm was excised surgically, and the fistula was closed with the right atrial wall with additional bypass grafts of the left internal thoracic artery (LITA) and gastroepiploic artery (GEA).     

Transannular patching for tetralogy of Fallot with an anomalous right coronary artery

A 7-year-old girl underwent transannular patching under the mobilized anomalous right coronary artery across the right ventricular outflow to treat progressing infundibular stenosis 6 years after total repair of the tetralogy of Fallot. The procedure completely relieved recurrent stenosis. Simultaneous angiography of the coronary artery and right ventricle were useful in precisely evaluating coronary anatomy.     

A surgical case of right coronary artery-right atrial fistula complicated with postoperative myocardial infarction

We report a 10-year-old girl with a right coronary artery-right atrial fistula and aneurysm formation. The proximal orifice was closed from the inside of the aneurysm, and the distal orifice through the right atrium under cardiopulmonary bypass. On the 9th postoperative day, myocardial infarction developed due to thrombosis in the fistula stump and the dilated coronary artery. Thrombosis may have been induced by postoperative dehydration and inadequate anticoagulant therapy. It is important to minimize a fistula stump and to strictly administer postoperative anticoagulant therapy.