Images in cardiovascular medicine voluminous left main stem to pulmonary artery fistula: A conservative approach

Abstract

The presence of a coronary arteriovenous fistula is almost rare in the adult population, even rare when associated with aortic valve insufficiency. Management and treatment options can vary and depend on a single patient. In our case, a large fistula with a rounded origin started from the roof of the left main stem, just attached to the wall of the aortic root, and finished with a very narrowed end in the pulmonary trunk. Due to its anatomical position and to the potential complications related to a proximal surgical closure as well as the incidental discovery in adult age (without signs or symptoms until the operation), we decided to have a conservative approach, leaving untouched the fistula. No intraoperative, perioperative, and follow-up signs of myocardial ischemia were observed. K E Y W O R D S coronary fistula, left main stem, pulmonary artery 1 | IMAGES IN CARDIOVASCULAR MEDICINE A coronary-pulmonary artery fistula (CPAF) is a rare cardiac abnormality, found in 0.3% to 0.8% of the patients. 1,2 The majority of coronary artery fistulae are related to the right coronary artery (55%), while 35% arise from the left anterior descending artery. Low-pressure structures are the most common sites of drainage of the coronary artery fistula which communicates with the right side of the heart in 90% of the case. 1-3 Most adult patients are usually asymptomatic and a fistula is incidentally identified by different cardiac imaging modalities. Nevertheless, it has been reported that CPAF can result in sudden cardiac death. 1 Management and treatment options can vary and depend on a single patient. The optimal treatment of CPAF is still a matter of debate considering the reduced number of clinical cases and the variability of anatomical conditions and presentation. Surgical intervention is usually indicated if there is a shunt of more than 30%, cardiac ischemia, advanced pulmonary hypertension or congestive heart failure, a history of infectious endocarditis, and/or aneurysmal formation. 1,2 A large fistula from the main stem roof (Figure 1A, white arrow) to the pulmonary artery trunk (Figure 1B, yellow arrow) was incidentally found by preoperative coronary angiography in a 63-yearold man with severe aortic regurgitation, symptomatic for mild efforts dyspnea. Angio-CT confirmed a retropulmonary course ( Figure 1C,D, red arrow). During surgery, we observed the large rounded origin ( Figure 1F, white arrow) starting from the roof of the left main stem, just attached to the wall of the posterior aortic root and under the right pulmonary artery, and its course finishing with a very narrowed end in the pulmonary trunk ( Figure 1E, yellow arrow).Distal closure at pulmonary level would have been easy to perform but, due to its anatomical origin and course and to the potential complications related to a proximal surgical ligation as well as the incidental discovery in an adult age (without signs or symptoms until the operation), we decided to prefer a conservative approach, leaving the fistula untouched. Aortic valve replacement...