Commentary: For unusual cases, preparation is key

Abstract

In this edition of the Journal, Albacker and colleagues 1 describe a case of left main and left anterior descending coronary artery ectasia fistulizing to the right ventricle in a 28-year-old female patient. The patient was initially diagnosed with an apical ventricular septal defect on transthoracic echocardiography, but intraoperatively the anomalies were identified and the fistula was closed with a bovine pericardial patch from the right ventricular side. Postoperatively, the patient was anticoagulated and repeat imaging 2 years later demonstrated no residual shunt and stable-sized coronary arteries.The authors were surprised on their initial intraoperative inspection when they saw ectatic coronary arteries and communication of the presumed ventricular septal defect with the distal coronary artery. They elected not to address the ectatic coronary artery in the operating room because they did not know the full coronary anatomy. Preoperative left heart catheterization would be unusual to perform on this young patient and hindsight is 20/20, but with congenital heart disease presenting in a 28-year-old patient, the authors should have considered cardiac magnetic resonance imaging. This could have provided a better ''roadmap'' with which to work and would likely have prompted a left heart catheterization, allowing them to address the coronary anomaly at the time of the initial operation.It is interesting that a left heart catheterization was not performed immediately after surgery, which would have allowed a more immediate intervention based on the findings.