Cardiovascular Anesthesia: Echo Didactics & Rounds
We present a patient with left main coronary artery to coronary sinus fistula in whom intraoperative transesophageal echocardiography (TEE) identified the precise location of the site of drainage of the fistula, which could not be accurately revealed with preoperative coronary arteriography, computed tomography, or transthoracic echocardiography. TEE was useful to confirm the absence of fistulous flow or new left ventricular regional wall motion abnormalities after fistula closure. We demonstrated the usefulness of intraoperative TEE in diagnosis and post-repair surgical evaluation for closure of coronary artery fistula (CAF).
CAF is an infrequent vascular anomaly that establishes a direct link between an epicardial coronary artery and a cardiac chamber, major vessels, or other vascular structures (1,2). The most common sites of drainage are low-pressure structures such as the pulmonary artery, right ventricle, and right atrium (1,2). Although coronary arteriography is the “gold standard” for the diagnosis of CAF, it is not always possible to reveal the complete delineation of CAF, especially its drainage. We report a case of a 66-yr-old woman scheduled to undergo closure of CAF and coronary artery bypass grafts, in whom a CAF was found on preoperative arteriography originating from a dilated left main coronary artery. Preoperative ex- aminations with coronary arteriography, computed tomography, and transthoracic echocardiography suggested its communication with the right atrium, but the precise site of drainage of the CAF could not be identified. Intraoperative TEE was performed using a 5-MHz multiplane probe (Hitachi Medical Corporation, Tokyo, Japan). Color flow Doppler at the mid-esophageal level identified abnormal turbulent inflow into the right atrium through the coronary sinus (Fig. 1). Surgical findings confirmed that the CAF communicated with the coronary sinus 5 mm proximal to its opening into the right atrium. After closure of the fistula at both its origin and drainage sites, TEE confirmed absence of fistulous flow into the right atrium through the coronary sinus (Fig. 1). Furthermore, TEE confirmed absence of regional wall motion abnormalities of the left ventricle that might have resulted from surgical closure of the CAF at its origin from the left main coronary artery. This case demonstrated the usefulness of intraoperative TEE to guide surgical closure of CAF.
1. Cheung DL, Au WK, Cheung HH, et al. Coronary artery fistulas: long-term results of surgical correction. Ann Thorac Surg 2001;71:190–5.
2. Vavuranakis M, Bush CA, Boudoulas H. Coronary artery fistulas in adults: incidence, angiographic characteristics, natural history. Cathet Cardiovasc Diagn 1995;35:116–20.