- Email: [email protected]
Single-Stage Minimally Invasive Surgery for Synchronous Primary Pulmonary Adenocarcinoma and Left Atrial Myxoma
2352
CASE REPORT VAN DER MERWE ET AL COMBINED VATS AND PAS
FEATURE ARTICLES
Comment This case confirms that even huge mediastinal tumors involving the heart and lungs, which seem at first sight to be inoperable, may be removed completely. The reported surgical therapy was considered a palliative approach because sarcomas of the heart have a poor prognosis [1– 5]. The main cause of the symptoms was low cardiac output resulting from the presence of the separate tumor in the LV. The tumor mechanically prevented adequate filling of the LV with blood, similar to mitral stenosis. The main aim was relief of symptoms and this was immediately achieved. Our patient lived an additional 22 months after the operation. Therefore, complete tumor extraction may influence long-term survival and enable subsequent adjuvant therapy. A procedure of this magnitude can be considered at centers familiar with all aspects of this extensive operation. It is important that it is discussed at full length preoperatively with the patient and his or her relatives. We made some important procedural observations from this single case: (1) optimal exposure of the operative field was achieved through a left thoracotomy; (2) the whole procedure could be performed on the beating heart (this enabled easy identification of any bleeding from the side branches of the circumflex coronary artery); (3) the tumor could be resected in toto even if it invaded mitral valve structures and neighboring left ventricular myocardium; (4) extensive dissection had to be done before the definitive judgment about operability was made (inoperability was our first impression because of the extent of the tumorous process, but dissection of the atrioventricular groove and mobilization of the complete LA with a tumorous block showed this impression to be incorrect); (5) intraoperative transesophageal echocardiography helped us to distinguish the tumorous mass from the normal tissue and also showed that the circumflex artery was not invaded by the tumor; and (6) the neoatrium was easily reconstructed using bovine pericardial patches sutured at the mitral valve annulus.
The authors wish to thank Anne Gale for editorial assistance, Katharina Wassilew, MD, for pathohistologic examinations, and Natalia Solowjowa, MD, and Ekaterina Ivanitskaia-K€ uhn, MD, for computed tomographic procedures.
Ann Thorac Surg 2015;100:2352–4
autotransplantation. J Thorac Cardiovasc Surg 2006;131: 731–3. 5. Shapira OM, Korach A, Izhar U, et al. Radical multidisciplinary approach to primary cardiac sarcomas. Eur J Cardiothorac Surg 2013;44:330–5.
Single-Stage Minimally Invasive Surgery for Synchronous Primary Pulmonary Adenocarcinoma and Left Atrial Myxoma Johan van der Merwe, MBChB, MMED (Thorax), Roel Beelen, MD, Sebastiaan Martens, MD, and Frank Van Praet, MD Department of Cardiovascular and Thoracic Surgery, OLV Hospital, Aalst, Belgium
We report the first successful short-term outcome of single-stage combined video-assisted thoracoscopic surgery lobectomy and port access surgery in a patient with operable primary right lower lobe adenocarcinoma and a synchronous cardiac myxoma. The video-assisted thoracic surgery right lower lobectomy with systematic lymph node dissection was performed first, followed by myxoma excision by port access surgery through the same working port incision. The histopathologic analysis confirmed a pT2a N0 M0 R0 (TNM 7th edition) primary poorly differentiated pulmonary adenocarcinoma and a completely excised cardiac myxoma. Postoperative recovery was uneventful, and follow-up at 6 weeks confirmed an excellent surgical and oncologic outcome. (Ann Thorac Surg 2015;100:2352–4) Ó 2015 by The Society of Thoracic Surgeons
T
he clinical application of video-assisted thoracoscopic surgery (VATS) for pulmonary oncologic resection and port access surgery (PAS) for intracardiac tumor excisions is well established in experienced centers [1, 2]. Synchronous primary pulmonary and intracardiac neoplasms are rare and traditionally surgically approached by staged or simultaneous open strategies that present significant morbidities and surgical risks [3]. We performed 2,851 PAS procedures since the initiation of our program in 1997, which includes 58 intracardiac oncologic resections. Our VATS program
References 1. Cooley DA, Reardon MJ, Frazier OH, Angelini P. Human cardiac explantation and autotransplantation: application in a patient with a large cardiac pheochromocytoma. Tex Heart Inst J 1985;12:171–6. 2. Dan S, Hodhe AJ. Osteogenic sarcoma of the left atrium. Ann Thorac Surg 1997;63:1766–8. 3. Reardon MJ, DeFelice CA, Sheinbaum R, Baldwin JC. Cardiac autotransplant for surgical treatment of a malignant neoplasm. Ann Thorac Surg 1999;67:1793–5. 4. Wang C-H, Yu H-Y, Chi N-S, et al. Complete excision of primary cardiac malignant fibrous histiocytoma involving the left atrial free wall and mitral annulus by modified Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
Accepted for publication Feb 12, 2015. Address correspondence to Dr Beelen, Department of Cardiovascular and Thoracic Surgery, OLV Hospital, Moorselbaan 164, 9300, Aalst, Belgium; e-mail: [email protected].
Dr Van Praet discloses a financial relationship with Edwards Lifesciences.
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2015.02.123
Ann Thorac Surg 2015;100:2352–4
CASE REPORT
VAN DER MERWE ET AL COMBINED VATS AND PAS
2353
Fig 1. (A, B) Oncologic surveillance with computed tomography imaging scans identified a right lower lobe apical mass. (C) Transesophageal echocardiographic imaging of a synchronous intracardiac mass.
was established in 2012. We report herein the first successful short-term outcome of single-stage VATS lobectomy, systematic nodal dissection (SND), and PAS in a patient with a synchronously occurring pulmonary adenocarcinoma and cardiac myxoma.
Fig 2. (A) Video-assisted thoracoscopic surgery port incisions, (B) resected right lower lobe specimen, (C) port access surgery left atrial visualization of myxoma, (D) intraatrial septal repair after myxoma excision, and (E) cosmetic result at 6 weeks’ follow-up.
FEATURE ARTICLES
Oncologic surveillance of a 70-year-old man identified an enlarging heterogeneous mass in the apical segment of his right lower lobe, 3 years after he underwent a left open thoracophrenolaparotomy and partial esophagectomy for stage 1 distal esophageal adenocarcinoma (pT1 N0 M0, TNM 7th edition). Computed tomography (CT), positron emission tomography (PET), and bone skeletal scintigraphy scans clearly defined the pulmonary malignancy (25-mm maximum diameter) and excluded distal metastases (Figs 1A, 1B). A left atrial mass (18-mm maximum diameter) of nonhomogeneous echogenicity that originated from the atrial septum was incidentally diagnosed and further investigated by transesophageal echocardiography (Fig 1C). The working diagnosis of synchronous cardiac myxoma and primary or metastatic pulmonary malignancy was proposed. Lung function tests and coronary catheterization were unremarkable. The patient elected the option of a
single-stage ipsilateral VATS and PAS approach as definitive diagnostic and therapeutic procedures. After general anesthesia, double-lumen tube intubation, and insertion of routine monitoring catheters, the patient was first placed in the left decubitus position. Anterior axillary ports were inserted in the third, fifth, and eighth intercostal spaces with an additional posterior axillary line port in the fifth intercostal space (Fig 2A). Routine dissection of adhesions, the inferior pulmonary ligament, and interlobar fissure was followed by division of the inferior pulmonary vein (Endo GIA 30 mm; Covidien, Mansfield, MA), pulmonary arterial branches (Endo GIA 30 mm; Covidien), and bronchus (Endo GIA 60 mm; Covidien). The right lower lobe was carefully maneuvered into an endobag (Endo Catch; Covidien), after which systematic nodal dissection of stations R2 to R10 was performed (Fig 2B). The patient was then positioned supine for PAS with venous drainage through the right internal jugular (16F to 18F, Optisite; Edwards Lifesciences, Irvine, CA) and femoral vein (22F or 25F, Quickdraw; Edwards Lifesciences). A femoral artery cannula with a Y arm (21F or 23F, Endoreturn; Edwards Lifesciences) was used for arterial flow, and an endoaortic balloon (IntraClude; Edwards
2354
CASE REPORT KIM ET AL PULMONARY VEIN FISTULAE
Lifesciences) was used for aortic occlusion and cold antegrade crystalloid cardioplegia delivery. The third intercostal space VATS port was extended anteriorly as a 4-cm working port, through which the endobag and resected lung were extracted. The endoscope and CO2 were introduced through the third and fifth intercostal VATS ports, respectively. An 18- 18-mm localized left atrial mass was excised from the intraatrial septum with 2- to 3-mm margins, and the resulting defect was primarily closed (Figs 2C, 2D). Removal of air was ensured by a venting catheter in the left atrium, antegrade balloon catheter venting, and transesophageal echocardiographic surveillance for residual air in the left ventricle. Cardiopulmonary bypass and ischemic times were 64 minutes and 34 minutes, respectively. Histopathologic and epidermal growth factor receptor analysis of the malignant pulmonary mass and lymph nodes confirmed the diagnosis of a pT2a N0 R0 Pl1 (TNM 7th edition) primary pulmonary adenocarcinoma with resistance to tyrosine kinase inhibitors. The histopathologic evaluation of the cardiac mass confirmed a completely excised cardiac myxoma. Patient recovery was swift, uneventful, and suitable for further home base care 7 days postoperatively. Clinical follow-up at 6 weeks revealed excellent physical, cosmetic, and oncologic recovery (Fig 2E).
FEATURE ARTICLES
Comment Single-stage ipsilateral minimally invasive surgery avoids the morbidity, cost, progressive tumor growth, and potential tumor dissemination associated with time delays in the traditional two-stage open procedures for specifically right-sided hemithoracic disease [3]. We acknowledge that certain rare metastatic lung carcinomas may arise on the cardiac septum and that some authors perform cardiac surgery first to exclude cardiac metastases [4]. We prefer to perform VATS before PAS to minimize the debatable risk of tumor dissemination and well-established coagulopathy effects related to cardiopulmonary bypass [5]. Our successful and potentially curative concomitant singlestage VATS and PAS oncologic resection resulted in a good clinical and cosmetic outcome, rapid patient recovery, and overall patient satisfaction.
References 1. Cao C, Manganas C, Ang SC, Yan TD. A meta-analysis of unmatched and matched patients comparing video-assisted thoracoscopic lobectomy and conventional open lobectomy. Ann Cardiothorac Surg 2012;1:16–23. 2. Deshpande RP, Casselman F, Bakir I, et al. Endoscopic cardiac tumor resection. Ann Thorac Surg 2007;83:2142–6. 3. Canver CC, Plehn JF. Concomitant occurrence of a left atrial myxoma and an adenocarcinoma of the lung. Clin Cardiol 1993;16:629–30. 4. Fu Q, Li Q-Z, Liang D-G, Ruan X-H, Wang Z-X, Wei M-X. Early and long-term results of combined cardiac surgery and neoplastic resection in patients with concomitant severe heart disease and neoplasms. Chin Med J (Engl) 2011;124: 1939–42. Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
Ann Thorac Surg 2015;100:2354–7
5. Danton MH, Anikin VA, McManus KG, McGuigan JA, Campalani G. Simultaneous cardiac surgery with pulmonary resection: presentation of series and review of literature. Eur J Cardiothorac Surg 1998;13:667–72.
Sequential Management of Coexisting Aorta-to-Pulmonary and Coronary-to-Pulmonary Vein Fistulae Mi-Na Kim, MD, Hee Jung Kim, MD, Sung Ho Hwang, MD, Jae Seung Jung, MD, PhD, Sung Bum Cho, MD, PhD, Cheol-Woong Yu, MD, PhD, Ho Sung Son, MD, PhD, and Wan-Joo Shim, MD, PhD Division of Cardiology, Department of Internal Medicine, and Department of Cardiovascular Surgery, Korea University Medical Center; and Department of Radiology, Korea University Anam Hospital, Seoul, Republic of Korea
In a 42-year-old man who presented with exertional dyspnea, a large fistula between the pulmonary vein and the left circumflex artery, and multiple aorta-topulmonary vein fistulae, were observed on coronary computed tomographic and magnetic resonance angiograms. Surgical ligation of the coronary artery-topulmonary vein fistula and coil embolization for two aorta-to-pulmonary vein fistulae were performed sequentially. The patient’s symptoms were relieved after fistula occlusion and recovery of hemodynamic values. (Ann Thorac Surg 2015;100:2354–7) Ó 2015 by The Society of Thoracic Surgeons
T
he coexistence of congenital aorta-to-pulmonary and coronary-to-pulmonary vein fistulae is extremely rare. Clinical features could consist of myocardial ischemia caused by the coronary steal phenomenon and high-output heart failure in the presence of a significant left-to-right shunt. We observed, and herein report, a case of congenital coronary-to-pulmonary and two aorta-topulmonary vein fistulae managed by surgical ligation and multiple percutaneous coil embolizations. A 42-year-old man without any significant medical history presented with New York Heart Association grade 3 exertional dyspnea and chest tightness. Cardiovascular examination revealed a loud continuous murmur at the left upper sternal border and epigastric area. His blood pressure was 150/70 mm Hg, and his pulse rate was 73 beats/minute. Chest radiography revealed generalized cardiomegaly with pulmonary congestion, and electrocardiography revealed left ventricular hypertrophy with ST-T changes. Echocardiography revealed dilatation of all Accepted for publication Feb 18, 2015. Address correspondence to Dr Shim, Korea University Cardiovascular Center, Korea University Anam Hospital, 126-1 Anam-dong 5-ga, Seongbuk-gu, Seoul 136-705, Republic of Korea; e-mail: wjshimmd@ unitel.co.kr.
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2015.02.100
CASE REPORT VAN DER MERWE ET AL COMBINED VATS AND PAS
FEATURE ARTICLES
Comment This case confirms that even huge mediastinal tumors involving the heart and lungs, which seem at first sight to be inoperable, may be removed completely. The reported surgical therapy was considered a palliative approach because sarcomas of the heart have a poor prognosis [1– 5]. The main cause of the symptoms was low cardiac output resulting from the presence of the separate tumor in the LV. The tumor mechanically prevented adequate filling of the LV with blood, similar to mitral stenosis. The main aim was relief of symptoms and this was immediately achieved. Our patient lived an additional 22 months after the operation. Therefore, complete tumor extraction may influence long-term survival and enable subsequent adjuvant therapy. A procedure of this magnitude can be considered at centers familiar with all aspects of this extensive operation. It is important that it is discussed at full length preoperatively with the patient and his or her relatives. We made some important procedural observations from this single case: (1) optimal exposure of the operative field was achieved through a left thoracotomy; (2) the whole procedure could be performed on the beating heart (this enabled easy identification of any bleeding from the side branches of the circumflex coronary artery); (3) the tumor could be resected in toto even if it invaded mitral valve structures and neighboring left ventricular myocardium; (4) extensive dissection had to be done before the definitive judgment about operability was made (inoperability was our first impression because of the extent of the tumorous process, but dissection of the atrioventricular groove and mobilization of the complete LA with a tumorous block showed this impression to be incorrect); (5) intraoperative transesophageal echocardiography helped us to distinguish the tumorous mass from the normal tissue and also showed that the circumflex artery was not invaded by the tumor; and (6) the neoatrium was easily reconstructed using bovine pericardial patches sutured at the mitral valve annulus.
The authors wish to thank Anne Gale for editorial assistance, Katharina Wassilew, MD, for pathohistologic examinations, and Natalia Solowjowa, MD, and Ekaterina Ivanitskaia-K€ uhn, MD, for computed tomographic procedures.
Ann Thorac Surg 2015;100:2352–4
autotransplantation. J Thorac Cardiovasc Surg 2006;131: 731–3. 5. Shapira OM, Korach A, Izhar U, et al. Radical multidisciplinary approach to primary cardiac sarcomas. Eur J Cardiothorac Surg 2013;44:330–5.
Single-Stage Minimally Invasive Surgery for Synchronous Primary Pulmonary Adenocarcinoma and Left Atrial Myxoma Johan van der Merwe, MBChB, MMED (Thorax), Roel Beelen, MD, Sebastiaan Martens, MD, and Frank Van Praet, MD Department of Cardiovascular and Thoracic Surgery, OLV Hospital, Aalst, Belgium
We report the first successful short-term outcome of single-stage combined video-assisted thoracoscopic surgery lobectomy and port access surgery in a patient with operable primary right lower lobe adenocarcinoma and a synchronous cardiac myxoma. The video-assisted thoracic surgery right lower lobectomy with systematic lymph node dissection was performed first, followed by myxoma excision by port access surgery through the same working port incision. The histopathologic analysis confirmed a pT2a N0 M0 R0 (TNM 7th edition) primary poorly differentiated pulmonary adenocarcinoma and a completely excised cardiac myxoma. Postoperative recovery was uneventful, and follow-up at 6 weeks confirmed an excellent surgical and oncologic outcome. (Ann Thorac Surg 2015;100:2352–4) Ó 2015 by The Society of Thoracic Surgeons
T
he clinical application of video-assisted thoracoscopic surgery (VATS) for pulmonary oncologic resection and port access surgery (PAS) for intracardiac tumor excisions is well established in experienced centers [1, 2]. Synchronous primary pulmonary and intracardiac neoplasms are rare and traditionally surgically approached by staged or simultaneous open strategies that present significant morbidities and surgical risks [3]. We performed 2,851 PAS procedures since the initiation of our program in 1997, which includes 58 intracardiac oncologic resections. Our VATS program
References 1. Cooley DA, Reardon MJ, Frazier OH, Angelini P. Human cardiac explantation and autotransplantation: application in a patient with a large cardiac pheochromocytoma. Tex Heart Inst J 1985;12:171–6. 2. Dan S, Hodhe AJ. Osteogenic sarcoma of the left atrium. Ann Thorac Surg 1997;63:1766–8. 3. Reardon MJ, DeFelice CA, Sheinbaum R, Baldwin JC. Cardiac autotransplant for surgical treatment of a malignant neoplasm. Ann Thorac Surg 1999;67:1793–5. 4. Wang C-H, Yu H-Y, Chi N-S, et al. Complete excision of primary cardiac malignant fibrous histiocytoma involving the left atrial free wall and mitral annulus by modified Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
Accepted for publication Feb 12, 2015. Address correspondence to Dr Beelen, Department of Cardiovascular and Thoracic Surgery, OLV Hospital, Moorselbaan 164, 9300, Aalst, Belgium; e-mail: [email protected].
Dr Van Praet discloses a financial relationship with Edwards Lifesciences.
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2015.02.123
Ann Thorac Surg 2015;100:2352–4
CASE REPORT
VAN DER MERWE ET AL COMBINED VATS AND PAS
2353
Fig 1. (A, B) Oncologic surveillance with computed tomography imaging scans identified a right lower lobe apical mass. (C) Transesophageal echocardiographic imaging of a synchronous intracardiac mass.
was established in 2012. We report herein the first successful short-term outcome of single-stage VATS lobectomy, systematic nodal dissection (SND), and PAS in a patient with a synchronously occurring pulmonary adenocarcinoma and cardiac myxoma.
Fig 2. (A) Video-assisted thoracoscopic surgery port incisions, (B) resected right lower lobe specimen, (C) port access surgery left atrial visualization of myxoma, (D) intraatrial septal repair after myxoma excision, and (E) cosmetic result at 6 weeks’ follow-up.
FEATURE ARTICLES
Oncologic surveillance of a 70-year-old man identified an enlarging heterogeneous mass in the apical segment of his right lower lobe, 3 years after he underwent a left open thoracophrenolaparotomy and partial esophagectomy for stage 1 distal esophageal adenocarcinoma (pT1 N0 M0, TNM 7th edition). Computed tomography (CT), positron emission tomography (PET), and bone skeletal scintigraphy scans clearly defined the pulmonary malignancy (25-mm maximum diameter) and excluded distal metastases (Figs 1A, 1B). A left atrial mass (18-mm maximum diameter) of nonhomogeneous echogenicity that originated from the atrial septum was incidentally diagnosed and further investigated by transesophageal echocardiography (Fig 1C). The working diagnosis of synchronous cardiac myxoma and primary or metastatic pulmonary malignancy was proposed. Lung function tests and coronary catheterization were unremarkable. The patient elected the option of a
single-stage ipsilateral VATS and PAS approach as definitive diagnostic and therapeutic procedures. After general anesthesia, double-lumen tube intubation, and insertion of routine monitoring catheters, the patient was first placed in the left decubitus position. Anterior axillary ports were inserted in the third, fifth, and eighth intercostal spaces with an additional posterior axillary line port in the fifth intercostal space (Fig 2A). Routine dissection of adhesions, the inferior pulmonary ligament, and interlobar fissure was followed by division of the inferior pulmonary vein (Endo GIA 30 mm; Covidien, Mansfield, MA), pulmonary arterial branches (Endo GIA 30 mm; Covidien), and bronchus (Endo GIA 60 mm; Covidien). The right lower lobe was carefully maneuvered into an endobag (Endo Catch; Covidien), after which systematic nodal dissection of stations R2 to R10 was performed (Fig 2B). The patient was then positioned supine for PAS with venous drainage through the right internal jugular (16F to 18F, Optisite; Edwards Lifesciences, Irvine, CA) and femoral vein (22F or 25F, Quickdraw; Edwards Lifesciences). A femoral artery cannula with a Y arm (21F or 23F, Endoreturn; Edwards Lifesciences) was used for arterial flow, and an endoaortic balloon (IntraClude; Edwards
2354
CASE REPORT KIM ET AL PULMONARY VEIN FISTULAE
Lifesciences) was used for aortic occlusion and cold antegrade crystalloid cardioplegia delivery. The third intercostal space VATS port was extended anteriorly as a 4-cm working port, through which the endobag and resected lung were extracted. The endoscope and CO2 were introduced through the third and fifth intercostal VATS ports, respectively. An 18- 18-mm localized left atrial mass was excised from the intraatrial septum with 2- to 3-mm margins, and the resulting defect was primarily closed (Figs 2C, 2D). Removal of air was ensured by a venting catheter in the left atrium, antegrade balloon catheter venting, and transesophageal echocardiographic surveillance for residual air in the left ventricle. Cardiopulmonary bypass and ischemic times were 64 minutes and 34 minutes, respectively. Histopathologic and epidermal growth factor receptor analysis of the malignant pulmonary mass and lymph nodes confirmed the diagnosis of a pT2a N0 R0 Pl1 (TNM 7th edition) primary pulmonary adenocarcinoma with resistance to tyrosine kinase inhibitors. The histopathologic evaluation of the cardiac mass confirmed a completely excised cardiac myxoma. Patient recovery was swift, uneventful, and suitable for further home base care 7 days postoperatively. Clinical follow-up at 6 weeks revealed excellent physical, cosmetic, and oncologic recovery (Fig 2E).
FEATURE ARTICLES
Comment Single-stage ipsilateral minimally invasive surgery avoids the morbidity, cost, progressive tumor growth, and potential tumor dissemination associated with time delays in the traditional two-stage open procedures for specifically right-sided hemithoracic disease [3]. We acknowledge that certain rare metastatic lung carcinomas may arise on the cardiac septum and that some authors perform cardiac surgery first to exclude cardiac metastases [4]. We prefer to perform VATS before PAS to minimize the debatable risk of tumor dissemination and well-established coagulopathy effects related to cardiopulmonary bypass [5]. Our successful and potentially curative concomitant singlestage VATS and PAS oncologic resection resulted in a good clinical and cosmetic outcome, rapid patient recovery, and overall patient satisfaction.
References 1. Cao C, Manganas C, Ang SC, Yan TD. A meta-analysis of unmatched and matched patients comparing video-assisted thoracoscopic lobectomy and conventional open lobectomy. Ann Cardiothorac Surg 2012;1:16–23. 2. Deshpande RP, Casselman F, Bakir I, et al. Endoscopic cardiac tumor resection. Ann Thorac Surg 2007;83:2142–6. 3. Canver CC, Plehn JF. Concomitant occurrence of a left atrial myxoma and an adenocarcinoma of the lung. Clin Cardiol 1993;16:629–30. 4. Fu Q, Li Q-Z, Liang D-G, Ruan X-H, Wang Z-X, Wei M-X. Early and long-term results of combined cardiac surgery and neoplastic resection in patients with concomitant severe heart disease and neoplasms. Chin Med J (Engl) 2011;124: 1939–42. Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
Ann Thorac Surg 2015;100:2354–7
5. Danton MH, Anikin VA, McManus KG, McGuigan JA, Campalani G. Simultaneous cardiac surgery with pulmonary resection: presentation of series and review of literature. Eur J Cardiothorac Surg 1998;13:667–72.
Sequential Management of Coexisting Aorta-to-Pulmonary and Coronary-to-Pulmonary Vein Fistulae Mi-Na Kim, MD, Hee Jung Kim, MD, Sung Ho Hwang, MD, Jae Seung Jung, MD, PhD, Sung Bum Cho, MD, PhD, Cheol-Woong Yu, MD, PhD, Ho Sung Son, MD, PhD, and Wan-Joo Shim, MD, PhD Division of Cardiology, Department of Internal Medicine, and Department of Cardiovascular Surgery, Korea University Medical Center; and Department of Radiology, Korea University Anam Hospital, Seoul, Republic of Korea
In a 42-year-old man who presented with exertional dyspnea, a large fistula between the pulmonary vein and the left circumflex artery, and multiple aorta-topulmonary vein fistulae, were observed on coronary computed tomographic and magnetic resonance angiograms. Surgical ligation of the coronary artery-topulmonary vein fistula and coil embolization for two aorta-to-pulmonary vein fistulae were performed sequentially. The patient’s symptoms were relieved after fistula occlusion and recovery of hemodynamic values. (Ann Thorac Surg 2015;100:2354–7) Ó 2015 by The Society of Thoracic Surgeons
T
he coexistence of congenital aorta-to-pulmonary and coronary-to-pulmonary vein fistulae is extremely rare. Clinical features could consist of myocardial ischemia caused by the coronary steal phenomenon and high-output heart failure in the presence of a significant left-to-right shunt. We observed, and herein report, a case of congenital coronary-to-pulmonary and two aorta-topulmonary vein fistulae managed by surgical ligation and multiple percutaneous coil embolizations. A 42-year-old man without any significant medical history presented with New York Heart Association grade 3 exertional dyspnea and chest tightness. Cardiovascular examination revealed a loud continuous murmur at the left upper sternal border and epigastric area. His blood pressure was 150/70 mm Hg, and his pulse rate was 73 beats/minute. Chest radiography revealed generalized cardiomegaly with pulmonary congestion, and electrocardiography revealed left ventricular hypertrophy with ST-T changes. Echocardiography revealed dilatation of all Accepted for publication Feb 18, 2015. Address correspondence to Dr Shim, Korea University Cardiovascular Center, Korea University Anam Hospital, 126-1 Anam-dong 5-ga, Seongbuk-gu, Seoul 136-705, Republic of Korea; e-mail: wjshimmd@ unitel.co.kr.
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2015.02.100