Intraoperative Epicardial Echocardiography Locates the Origin of a Coronary -Pulmonary Artery Fistula.

Abstract

CaseA 58-year-old man with post-infarction angina complicated by a congenital coronary-pulmonary artery fistula (CPAF) was referred for surgery. He had a stent placed in the left anterior descending artery (LAD) 3 months prior and was diagnosed with restenosis at the proximal site of the stent, where the fistula originated. No heart murmur was audible on the auscultation. CAG showed 90% stenosis of the proximal LAD and an aneurysmal fistula between the LAD and the main pulmonary artery (mPA) (Figure 1-a). Enhanced CT demonstrated an aneurysmal CPAF 3x4 cm in diameter in the right ventricular outflow tract (RVOT) (Figure 1-b). He was anemic and was a Jehovah's Witness. Coil embolization to the CPAF was not indicated because of an adjacent location between the origin of fragile CPAF and the restenosis site of the LAD. Off-pump CABG concomitant with coronary aneurysmectomy was planned to reduce blood loss. After the induction of the anesthesia, transesophageal echocardiography (TEE) was performed but the origin or the drainage site of blood flow in the fistula could not be located. The heart was exposed via a median sternotomy. A thrill was palpated at the anterior surface of the mPA, where the fistula drained but the artery feeding the fistula was not found by inspection or palpation. Epicardial echocardiography using a 7.5-MHz transducer (SONOS2000, Hewlett-Packard Japan Ltd, Tokyo) located the artery feeding the fistula. Two feeding arteries with a mosaic flow pattern were found in the myocardium of the RVOT (Figure 2). CABG using the left internal thoracic artery to the mid-LAD was performed. A drainage artery of CAPF was ligated on the surface of the mPA. Then the aneurysmal fistula AbstractThe clinical usefulness of intraoperative epicardial echocardiography in a patient with post-infarction angina complicated by a coronary-pulmonary artery fistula (CPAF) with aneurysmal change was reported. Epicardial echocardiography clearly showed feeding arteries to the fistula in the myocardium, which was not revealed by visual inspection, palpation, or transesophageal echocardiography. The patient was received off-pump coronary artery bypass grafting concomitant with aneurysmectomy. The feeding arteries were dissected easily using an ultrasonic scalpel and successfully ligated.The flow in the aneurysm disappeared immediately and aneurysmectomy was performed without bleeding.Intraoperative epicardial echocardiography was useful method during off-pump resection of CPAF.