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Concomitant Traumatic Aortic Valve and Coronary Artery Injury
Concomitant Traumatic Aortic Valve and Coronary Artery Injury Shigeaki Aoyagi, MD, Teiji Okazaki, MD, Shuji Fukunaga, MD, and Tomohiro Ueda, MD Department of Surgery, Kurume University School of Medicine, Kurume, Japan
A 79-year-old man, who had sustained nonpenetrating chest trauma 1 month previously, was admitted for dyspnea. Echocardiography demonstrated prolapse of the noncoronary aortic cusp with severe regurgitation. Aortography showed no intimal flap in the ascending aorta. Coronary arteriography showed dissection extending from the left main trunk to the proximal circumflex artery. At surgery, no abnormalities were found in the aortic wall or around the left coronary ostium. Avulsion of the commissure between the right coronary cusp and the noncoronary cusp from its aortic wall attachment was detected. Aortic valve replacement and coronary artery bypass grafting were performed. (Ann Thorac Surg 2007;83:289 –91) © 2007 by The Society of Thoracic Surgeons
T
raumatic aortic valve rupture [1, 2] and traumatic coronary artery injury are both rare complications of nonpenetrating cardiac injury [3, 4]. Traumatic dissection of the left main coronary artery is particularly unusual [3]. In this report, we describe the case of a patient who sustained nonpenetrating cardiac trauma that resulted in concomitant aortic valve rupture and dissection of the left main coronary artery. A 79-year-old man was admitted because of dyspnea on exertion. One month before admission, the patient had sustained left hemopneumothorax and fractures of the left clavicle and ribs as the result of a road traffic accident. The patient had been conservatively treated by chest tube drainage, but he had only a vague memory of medical examinations performed at the time. Three months before the traffic accident, the patient had received electrocardiographic and echocardiographic evaluations, and no cardiac abnormalities had been diagnosed. On admission, auscultation of the chest revealed a to-and-fro murmur along the left sternal border. A chest roentgenogram showed mild cardiomegaly with pulmonary congestion and pleural effusion. An electrocardiogram revealed normal sinus rhythm and left ventricular hypertrophy with T wave inversion in leads V1-4. Echocardiography demonstrated marked left ventricular dilatation with moderate anteroseptal hypokinesis and prolapse of the noncoronary cusp with severe regurgitation. Moderate pericardial effusion was also detected. Accepted for publication June 1, 2006. Address correspondence to Dr Aoyagi, Department of Surgery (2), Kurume University School of Medicine, 67 Asahi-machi, Kurume 830 – 0011, Japan; e-mail: [email protected].
© 2007 by The Society of Thoracic Surgeons Published by Elsevier Inc
CASE REPORT AOYAGI ET AL AORTIC VALVE AND CORONARY ARTERY INJURY
289
Cardiac catheterization revealed moderate pulmonary hypertension and high left ventricular end-diastolic pressure. Aortography indicated severe aortic regurgitation but no intimal flap in the ascending aorta and no dilatation of the sinus of Valsalva was observed. Coronary arteriography showed dissection extending from the left main trunk to the proximal circumflex artery resulting in 50% stenosis of the left main trunk and significant stenosis (90%) of the posterolateral branch (Fig 1). Luminal irregularities were observed but no significant stenosis was found in the rest of the coronary arteries. At surgery, a moderate amount of sanguineous pericardial effusion was noted. No abnormalities such as dissection or hematoma were found in the aortic wall or in the area of the left coronary ostium. No tears or lacerations were present in either aortic cusp. Avulsion of the commissure between the right coronary cusp and the noncoronary cusp from its aortic wall attachment, leading to prolapse of these two cusps was detected, as shown in Figure 2. This avulsed commissure was fibrous and strongly stiffened, but the valve leaflets themselves were grossly normal. In addition to coronary artery bypass grafting to the left anterior descending and posterolateral arteries, the aortic valve was replaced with a bovine pericardial valve. The patient recovered uneventfully. At follow-up 12 months later, he is asymptomatic with a normally functioning aortic prosthetic valve and a decrease of left ventricular dilatation by echocardiography.
Comment The frequency of high-speed traffic accidents has increased the incidence of nonpenetrating aortic and cardiac injuries. Cardiac valve injuries are uncommon, but aortic valve injuries are the most commonly encountered valvular lesion in patients surviving nonpenetrating cardiac injury [1, 2]. Coronary artery injury in patients with nonpenetrating chest trauma is also rare, and traumatic dissection of the left main coronary artery is even more unusual [3, 4]. Here we have described concomitant traumatic aortic valve rupture and coronary artery dissection. A sudden increase in intrathoracic pressure leading to a concomitant increase in intraaortic pressure by a compressive or deceleration injury applied during early diastole is the main mechanism of aortic valve injuries such as tears of the cusps or avulsion of the commissures [1, 2]. The noncoronary cusp is most commonly involved because the runoff into the coronary arterial system protects the corresponding cusps by reducing the hydrostatic force against them [5]. Although some cases required immediate emergent operation, many previous studies [2, 6] have indicated patients who sustained traumatic aortic regurgitation had a variable asymptomatic period of weeks to years. A mechanism for delay between trauma and onset of symptoms has been speculated as an initially small tear of the cusp at its attachment to the valve ring progressively extends as the result of ordinary hemodynamic stresses. As the valve cusp becomes separated from its annular attachment, aortic regurgitation progresses with a compensatory increase in 0003-4975/07/$32.00 doi:10.1016/j.athoracsur.2006.06.021
FEATURE ARTICLES
Ann Thorac Surg 2007;83:289 –91
290
CASE REPORT AOYAGI ET AL AORTIC VALVE AND CORONARY ARTERY INJURY
Ann Thorac Surg 2007;83:289 –91
FEATURE ARTICLES
Fig 1. Coronary arteriograms show the dissection, which extended from the left main trunk to the proximal circumflex artery, the resultant 50% stenosis of the left main trunk (white arrows), and significant stenosis (90%) of the posterolateral branch (black arrow). (A) The right anterior oblique position. (B) The left anterior oblique position.
the force of ejection and consequent increased hemodynamic stress on the valve cusp. When aortic regurgitation becomes severe enough to cause pulmonary congestion, patients become symptomatic [6]. Valve replacement with a prosthetic valve has been the most common method to correct traumatic aortic regurgitation; however, successful valve repair was also reported [5]. In our patient, aortic valve replacement was performed because the avulsed commissure was too fibrous and stiffened to permit preservation of his native valve. Coronary artery injury resulting from nonpenetrating chest trauma most often affects the left anterior descending artery [4]. The higher incidence of left anterior descending artery involvement may be due to its prox-
imity to the chest wall. Compression of the anterior chest wall and the shear forces in the arterial wall generated by the sudden deceleration during impact are presumed to be the cause of the arterial injury [7]. Because electrocardiographic abnormalities or cardiac enzyme elevation may be the only indicators of myocardial and specific coronary artery injury, coronary arteriography should be urgently performed in patients with such abnormalities to limit the extent of infarction by catheter or surgical intervention. Spontaneous healing of a coronary artery dissection has been reported in several cases [7]; however, surgical intervention, such as repair of dissection or coronary artery bypass grafting, is generally advocated [3, 8]. We performed coronary artery bypass grafting because it is a reliable and established procedure for securing coronary blood flow. In conclusion, we describe the case of a patient who sustained nonpenetrating cardiac trauma that resulted in concomitant aortic valve rupture and dissection of the left main coronary artery. The patient was successfully managed with aortic valve replacement and coronary artery bypass grafting.
References
Fig 2. An operative photograph (surgeon’s view) shows avulsion of the commissure between the right coronary cusp and noncoronary cusp (left arrow) from its aortic wall attachment (right arrow), allowing prolapse of these two cusps.
1. Payne DD, Deweese JA, Mahoney EB, Murphy GW. Surgical treatment of traumatic rupture of the normal aortic valve. Ann Thorac Surg 1974;17:223–9. 2. Parry GW, Wilkinson GAL. Traumatic aortic regurgitation. Injury 1997;28:679 – 80. 3. Harada H, Honma Y, Hachiro Y, Mawatari T, Abe T. Traumatic coronary artery dissection. Ann Thorac Surg 2002;74:236 –237. 4. Reiss J, Razzouk AJ, Kiev J, Vansal R, Bailey LL. Concomitant traumatic coronary artery and tricuspid valve injury: A heterogenous presentation. J Trauma 2001;50:942– 4.
CASE REPORT SAID ET AL SURGICAL TREATMENT OF BILATERAL ANEURYSMAL FISTULAS
5. Haskins CD, Shapira N, Rahman E, Serra AJ, McNicholas KW, Lemole GM. Repair of traumatic rupture of the aortic valve. Arch Surg 1992;127:231–2. 6. Gay JA, Gottdiener JS, Gomes MN, Patterson RH, Fletcher RD. Echocardiographic features of traumatic disruption of the aortic valve. Chest 1983;83:150 –1. 7. Neiman J, Hui WKK. Posteromedial papillary muscle rupture as a result of right coronary artery occlusion after blunt chest trauma. Am Heart J 1992:123:1694 –7. 8. Westaby S, Drossos G, Giannopoulos N. Posttraumatic coronary artery aneurysm. Ann Thorac Surg 1995;60:712–3.
Surgical Treatment of Bilateral Aneurysmal Coronary to Pulmonary Artery Fistulas Associated With Severe Atherosclerosis Salah A. M. Said, MD, Willem G. de Voogt, MD, PhD, Mohamed Soliman Hamad, MD, and Jacques Schonberger, MD, PhD Departments of Cardiology, Hospital Group Twente, Hengelo, St. Lucas Andreas Hospital, Amsterdam, and Department of Cardiothoracic Surgery, Catharina Hospital, Eindhoven, the Netherlands
A 39-year-old diabetic patient with an old inferior wall infarction presented with disabling angina pectoris, despite medical treatment. Coronary angiography showed severe triple-vessel coronary artery disease, and bilateral coronary to pulmonary fistulas originating from the right coronary artery and the left anterior descending coronary artery. Both coronary artery saphenous vein bypass grafting and ligation of the fistulas was performed. (Ann Thorac Surg 2007;83:291–3) © 2007 by The Society of Thoracic Surgeons
T
he indications for closure of coronary artery fistulas associated with or without coronary artery narrowing are discussed. It is pointed out that coronary fistulas may promote progression of existing atherosclerotic coronary artery disease distal to the fistula. Congenital solitary coronary artery fistulas may originate from one (unilateral), two (bilateral), or three (multilateral) coronary arteries. They may terminate in any of the cardiac chambers or intrathoracic large vessels with relatively low pressure. Coronary to pulmonary artery fistulas (CPFs) comprise 15% to 20% of the fistulas [1]. Coronary to pulmonary artery fistulas may present asymptomatically. When symptomatic, they can cause angina pectoris, ventricular or supraventricular arrhythmias, congestive heart failure, and infective endocarditis [2, 3]. Small-sized fistulas are conservatively and medically treated and further managed by a careful follow-up. However, large-sized symptomatic fistulas are treated Accepted for publication May 10, 2006. Address correspondence to Dr Said, Department of Cardiology, Hospital Group Twente, Geerdinksweg DL Hengelo, 141, 7555 the Netherlands; e-mail: [email protected].
© 2007 by The Society of Thoracic Surgeons Published by Elsevier Inc
291
either by percutaneous embolization or by surgical ligation, depending on the anatomical characteristics of the fistula [3]. A 39-year-old man with diabetes who sustained an inferior wall myocardial infarction some years previously, presented with severe angina, which persisted despite extensive medical treatment. On physical examination a continuous cardiac murmur was heard at the second left intercostal space. Further findings were unremarkable. The electrocardiogram showed an old inferior wall infarction and the exercise stress test was indicative for myocardial ischemia and angina pectoris at 70% of target heart rate. The coronary arteriogram demonstrated significant three-vessel disease and bilateral coronary to pulmonary fistulas (Fig 1). The fistulas were photographed during surgery (Fig 2). It was noticed that the left anterior descending coronary artery was small and of poor quality. Triple-saphenous vein coronary bypass surgery combined with dual ligation of the fistulas was performed. The proximal ends of the fistulas were ligated using 3-0 nonabsorbable ligature. The distal ends on the pulmonary artery side were electrocauterized or sutured with a nonabsorbable suture. A venous jump graft was used to graft the left anterior descending coronary artery, first obtuse marginal branch of the circumflex artery, and the posterior descending coronary artery of the right coronary artery. The operative and postoperative courses were uneventful.
Comment In CPFs, the fistula originates from the coronary arteries and drains with equal frequency into the right or left pulmonary arteries [4]. Baim and colleagues [2] reported a series of 363 cases, including 19 cases (5%) of bilateral fistulas. They showed that bilateral fistulas more often (50%) terminate into the pulmonary artery than unilateral fistulas (17%) [2]. In a recent Dutch Registry of congenital solitary fistulas in 51 adult patients, 16% of the fistulas were bilateral. When unilateral coronary artery fistulas (80%) were present, 33% originated from the right, 18% from the circumflex, and 46% from the left anterior descending coronary arteries. Aneurysmal formation was reported in 35% of the patients. Nearly all fistulas (97%) were tortuous and 27% demonstrated multiplicity of origin. Multiplicity of exits was found in 33% of coronary artery fistulas. Surgical ligation combined during valvular and coronary surgical procedures was performed in 25% of the cases, percutaneous therapeutic embolization in 5%, and 70% were treated by conservative medical management [5]. Whether the fistulas are unilateral, bilateral, or multilateral, in the presence or absence of atherosclerotic coronary artery disease, angina pectoris may be one of 0003-4975/07/$32.00 doi:10.1016/j.athoracsur.2006.05.033
FEATURE ARTICLES
Ann Thorac Surg 2007;83:291–3
A 79-year-old man, who had sustained nonpenetrating chest trauma 1 month previously, was admitted for dyspnea. Echocardiography demonstrated prolapse of the noncoronary aortic cusp with severe regurgitation. Aortography showed no intimal flap in the ascending aorta. Coronary arteriography showed dissection extending from the left main trunk to the proximal circumflex artery. At surgery, no abnormalities were found in the aortic wall or around the left coronary ostium. Avulsion of the commissure between the right coronary cusp and the noncoronary cusp from its aortic wall attachment was detected. Aortic valve replacement and coronary artery bypass grafting were performed. (Ann Thorac Surg 2007;83:289 –91) © 2007 by The Society of Thoracic Surgeons
T
raumatic aortic valve rupture [1, 2] and traumatic coronary artery injury are both rare complications of nonpenetrating cardiac injury [3, 4]. Traumatic dissection of the left main coronary artery is particularly unusual [3]. In this report, we describe the case of a patient who sustained nonpenetrating cardiac trauma that resulted in concomitant aortic valve rupture and dissection of the left main coronary artery. A 79-year-old man was admitted because of dyspnea on exertion. One month before admission, the patient had sustained left hemopneumothorax and fractures of the left clavicle and ribs as the result of a road traffic accident. The patient had been conservatively treated by chest tube drainage, but he had only a vague memory of medical examinations performed at the time. Three months before the traffic accident, the patient had received electrocardiographic and echocardiographic evaluations, and no cardiac abnormalities had been diagnosed. On admission, auscultation of the chest revealed a to-and-fro murmur along the left sternal border. A chest roentgenogram showed mild cardiomegaly with pulmonary congestion and pleural effusion. An electrocardiogram revealed normal sinus rhythm and left ventricular hypertrophy with T wave inversion in leads V1-4. Echocardiography demonstrated marked left ventricular dilatation with moderate anteroseptal hypokinesis and prolapse of the noncoronary cusp with severe regurgitation. Moderate pericardial effusion was also detected. Accepted for publication June 1, 2006. Address correspondence to Dr Aoyagi, Department of Surgery (2), Kurume University School of Medicine, 67 Asahi-machi, Kurume 830 – 0011, Japan; e-mail: [email protected].
© 2007 by The Society of Thoracic Surgeons Published by Elsevier Inc
CASE REPORT AOYAGI ET AL AORTIC VALVE AND CORONARY ARTERY INJURY
289
Cardiac catheterization revealed moderate pulmonary hypertension and high left ventricular end-diastolic pressure. Aortography indicated severe aortic regurgitation but no intimal flap in the ascending aorta and no dilatation of the sinus of Valsalva was observed. Coronary arteriography showed dissection extending from the left main trunk to the proximal circumflex artery resulting in 50% stenosis of the left main trunk and significant stenosis (90%) of the posterolateral branch (Fig 1). Luminal irregularities were observed but no significant stenosis was found in the rest of the coronary arteries. At surgery, a moderate amount of sanguineous pericardial effusion was noted. No abnormalities such as dissection or hematoma were found in the aortic wall or in the area of the left coronary ostium. No tears or lacerations were present in either aortic cusp. Avulsion of the commissure between the right coronary cusp and the noncoronary cusp from its aortic wall attachment, leading to prolapse of these two cusps was detected, as shown in Figure 2. This avulsed commissure was fibrous and strongly stiffened, but the valve leaflets themselves were grossly normal. In addition to coronary artery bypass grafting to the left anterior descending and posterolateral arteries, the aortic valve was replaced with a bovine pericardial valve. The patient recovered uneventfully. At follow-up 12 months later, he is asymptomatic with a normally functioning aortic prosthetic valve and a decrease of left ventricular dilatation by echocardiography.
Comment The frequency of high-speed traffic accidents has increased the incidence of nonpenetrating aortic and cardiac injuries. Cardiac valve injuries are uncommon, but aortic valve injuries are the most commonly encountered valvular lesion in patients surviving nonpenetrating cardiac injury [1, 2]. Coronary artery injury in patients with nonpenetrating chest trauma is also rare, and traumatic dissection of the left main coronary artery is even more unusual [3, 4]. Here we have described concomitant traumatic aortic valve rupture and coronary artery dissection. A sudden increase in intrathoracic pressure leading to a concomitant increase in intraaortic pressure by a compressive or deceleration injury applied during early diastole is the main mechanism of aortic valve injuries such as tears of the cusps or avulsion of the commissures [1, 2]. The noncoronary cusp is most commonly involved because the runoff into the coronary arterial system protects the corresponding cusps by reducing the hydrostatic force against them [5]. Although some cases required immediate emergent operation, many previous studies [2, 6] have indicated patients who sustained traumatic aortic regurgitation had a variable asymptomatic period of weeks to years. A mechanism for delay between trauma and onset of symptoms has been speculated as an initially small tear of the cusp at its attachment to the valve ring progressively extends as the result of ordinary hemodynamic stresses. As the valve cusp becomes separated from its annular attachment, aortic regurgitation progresses with a compensatory increase in 0003-4975/07/$32.00 doi:10.1016/j.athoracsur.2006.06.021
FEATURE ARTICLES
Ann Thorac Surg 2007;83:289 –91
290
CASE REPORT AOYAGI ET AL AORTIC VALVE AND CORONARY ARTERY INJURY
Ann Thorac Surg 2007;83:289 –91
FEATURE ARTICLES
Fig 1. Coronary arteriograms show the dissection, which extended from the left main trunk to the proximal circumflex artery, the resultant 50% stenosis of the left main trunk (white arrows), and significant stenosis (90%) of the posterolateral branch (black arrow). (A) The right anterior oblique position. (B) The left anterior oblique position.
the force of ejection and consequent increased hemodynamic stress on the valve cusp. When aortic regurgitation becomes severe enough to cause pulmonary congestion, patients become symptomatic [6]. Valve replacement with a prosthetic valve has been the most common method to correct traumatic aortic regurgitation; however, successful valve repair was also reported [5]. In our patient, aortic valve replacement was performed because the avulsed commissure was too fibrous and stiffened to permit preservation of his native valve. Coronary artery injury resulting from nonpenetrating chest trauma most often affects the left anterior descending artery [4]. The higher incidence of left anterior descending artery involvement may be due to its prox-
imity to the chest wall. Compression of the anterior chest wall and the shear forces in the arterial wall generated by the sudden deceleration during impact are presumed to be the cause of the arterial injury [7]. Because electrocardiographic abnormalities or cardiac enzyme elevation may be the only indicators of myocardial and specific coronary artery injury, coronary arteriography should be urgently performed in patients with such abnormalities to limit the extent of infarction by catheter or surgical intervention. Spontaneous healing of a coronary artery dissection has been reported in several cases [7]; however, surgical intervention, such as repair of dissection or coronary artery bypass grafting, is generally advocated [3, 8]. We performed coronary artery bypass grafting because it is a reliable and established procedure for securing coronary blood flow. In conclusion, we describe the case of a patient who sustained nonpenetrating cardiac trauma that resulted in concomitant aortic valve rupture and dissection of the left main coronary artery. The patient was successfully managed with aortic valve replacement and coronary artery bypass grafting.
References
Fig 2. An operative photograph (surgeon’s view) shows avulsion of the commissure between the right coronary cusp and noncoronary cusp (left arrow) from its aortic wall attachment (right arrow), allowing prolapse of these two cusps.
1. Payne DD, Deweese JA, Mahoney EB, Murphy GW. Surgical treatment of traumatic rupture of the normal aortic valve. Ann Thorac Surg 1974;17:223–9. 2. Parry GW, Wilkinson GAL. Traumatic aortic regurgitation. Injury 1997;28:679 – 80. 3. Harada H, Honma Y, Hachiro Y, Mawatari T, Abe T. Traumatic coronary artery dissection. Ann Thorac Surg 2002;74:236 –237. 4. Reiss J, Razzouk AJ, Kiev J, Vansal R, Bailey LL. Concomitant traumatic coronary artery and tricuspid valve injury: A heterogenous presentation. J Trauma 2001;50:942– 4.
CASE REPORT SAID ET AL SURGICAL TREATMENT OF BILATERAL ANEURYSMAL FISTULAS
5. Haskins CD, Shapira N, Rahman E, Serra AJ, McNicholas KW, Lemole GM. Repair of traumatic rupture of the aortic valve. Arch Surg 1992;127:231–2. 6. Gay JA, Gottdiener JS, Gomes MN, Patterson RH, Fletcher RD. Echocardiographic features of traumatic disruption of the aortic valve. Chest 1983;83:150 –1. 7. Neiman J, Hui WKK. Posteromedial papillary muscle rupture as a result of right coronary artery occlusion after blunt chest trauma. Am Heart J 1992:123:1694 –7. 8. Westaby S, Drossos G, Giannopoulos N. Posttraumatic coronary artery aneurysm. Ann Thorac Surg 1995;60:712–3.
Surgical Treatment of Bilateral Aneurysmal Coronary to Pulmonary Artery Fistulas Associated With Severe Atherosclerosis Salah A. M. Said, MD, Willem G. de Voogt, MD, PhD, Mohamed Soliman Hamad, MD, and Jacques Schonberger, MD, PhD Departments of Cardiology, Hospital Group Twente, Hengelo, St. Lucas Andreas Hospital, Amsterdam, and Department of Cardiothoracic Surgery, Catharina Hospital, Eindhoven, the Netherlands
A 39-year-old diabetic patient with an old inferior wall infarction presented with disabling angina pectoris, despite medical treatment. Coronary angiography showed severe triple-vessel coronary artery disease, and bilateral coronary to pulmonary fistulas originating from the right coronary artery and the left anterior descending coronary artery. Both coronary artery saphenous vein bypass grafting and ligation of the fistulas was performed. (Ann Thorac Surg 2007;83:291–3) © 2007 by The Society of Thoracic Surgeons
T
he indications for closure of coronary artery fistulas associated with or without coronary artery narrowing are discussed. It is pointed out that coronary fistulas may promote progression of existing atherosclerotic coronary artery disease distal to the fistula. Congenital solitary coronary artery fistulas may originate from one (unilateral), two (bilateral), or three (multilateral) coronary arteries. They may terminate in any of the cardiac chambers or intrathoracic large vessels with relatively low pressure. Coronary to pulmonary artery fistulas (CPFs) comprise 15% to 20% of the fistulas [1]. Coronary to pulmonary artery fistulas may present asymptomatically. When symptomatic, they can cause angina pectoris, ventricular or supraventricular arrhythmias, congestive heart failure, and infective endocarditis [2, 3]. Small-sized fistulas are conservatively and medically treated and further managed by a careful follow-up. However, large-sized symptomatic fistulas are treated Accepted for publication May 10, 2006. Address correspondence to Dr Said, Department of Cardiology, Hospital Group Twente, Geerdinksweg DL Hengelo, 141, 7555 the Netherlands; e-mail: [email protected].
© 2007 by The Society of Thoracic Surgeons Published by Elsevier Inc
291
either by percutaneous embolization or by surgical ligation, depending on the anatomical characteristics of the fistula [3]. A 39-year-old man with diabetes who sustained an inferior wall myocardial infarction some years previously, presented with severe angina, which persisted despite extensive medical treatment. On physical examination a continuous cardiac murmur was heard at the second left intercostal space. Further findings were unremarkable. The electrocardiogram showed an old inferior wall infarction and the exercise stress test was indicative for myocardial ischemia and angina pectoris at 70% of target heart rate. The coronary arteriogram demonstrated significant three-vessel disease and bilateral coronary to pulmonary fistulas (Fig 1). The fistulas were photographed during surgery (Fig 2). It was noticed that the left anterior descending coronary artery was small and of poor quality. Triple-saphenous vein coronary bypass surgery combined with dual ligation of the fistulas was performed. The proximal ends of the fistulas were ligated using 3-0 nonabsorbable ligature. The distal ends on the pulmonary artery side were electrocauterized or sutured with a nonabsorbable suture. A venous jump graft was used to graft the left anterior descending coronary artery, first obtuse marginal branch of the circumflex artery, and the posterior descending coronary artery of the right coronary artery. The operative and postoperative courses were uneventful.
Comment In CPFs, the fistula originates from the coronary arteries and drains with equal frequency into the right or left pulmonary arteries [4]. Baim and colleagues [2] reported a series of 363 cases, including 19 cases (5%) of bilateral fistulas. They showed that bilateral fistulas more often (50%) terminate into the pulmonary artery than unilateral fistulas (17%) [2]. In a recent Dutch Registry of congenital solitary fistulas in 51 adult patients, 16% of the fistulas were bilateral. When unilateral coronary artery fistulas (80%) were present, 33% originated from the right, 18% from the circumflex, and 46% from the left anterior descending coronary arteries. Aneurysmal formation was reported in 35% of the patients. Nearly all fistulas (97%) were tortuous and 27% demonstrated multiplicity of origin. Multiplicity of exits was found in 33% of coronary artery fistulas. Surgical ligation combined during valvular and coronary surgical procedures was performed in 25% of the cases, percutaneous therapeutic embolization in 5%, and 70% were treated by conservative medical management [5]. Whether the fistulas are unilateral, bilateral, or multilateral, in the presence or absence of atherosclerotic coronary artery disease, angina pectoris may be one of 0003-4975/07/$32.00 doi:10.1016/j.athoracsur.2006.05.033
FEATURE ARTICLES
Ann Thorac Surg 2007;83:291–3