| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
|
© 2004 European Association of Cardio-Thoracic Surgery
Integrated procedure for giant right coronary aneurysm with fistula and atrial fibrillation – coronary grafting, fistula obliteration and radiofrequency mazeDepartment of Cardiothoracic Surgery, Royal Prince Alfred Hospital, Missenden Road, Camperdown, NSW, Australia
* Corresponding author. Tel.: +61-2-9550-1933; fax: +61-2-9550-6669 Received September 4, 2003; received in revised form October 23, 2003; accepted November 10, 2003
Giant coronary artery aneurysm (CAA) with fistula is a rare entity. Surgical treatment is often concomitant to treating obstructing coronary lesions. We report the successful management of a giant right CAA with fistulisation into the right atrium. By coincidence, a secundum atrial septal defect was present. In addition, a radiofrequency maze procedure was performed for atrial fibrillation (AF). This combination of procedures has not been previously reported in the literature. The substantial benefits from regained atrial rhythm and contraction outweigh the potential risks, justifying the combined approach in patients with established AF and organic disorders provided the patients are judged capable of tolerating and benefiting from the procedure.
Key Words: Coronary aneurysms; Coronary fistulae; Radiofrequency maze
A 63-year-old male presented with chest pain, palpitations and chronic atrial fibrillation (AF). Transthoracic echocardiogram revealed a right coronary (RCA) aneurysm with a fistulous opening into the right atrium (RA). CT scan showed a rounded lesion adjacent to the right ventricle (Fig. 1). Angiography confirmed these findings (Fig. 2A and B). The distal vessel was occluded. Cardiac catheterization confirmed a left-to-right atrial shunt, with a pulmonary-to-systemic flow ratio of 1:4:1.
Through a median sternotomy the right mammary artery (RIMA) was harvested. The aneurysm lay posteromedial to the RA and the superior vena cava (SVC). Cardiopulmonary bypass was established through aorto bicaval cannulation, with caval snares and the patient was cooled to 30 °C. Cardiac arrest was induced using antegrade and retrograde cold blood cardioplegia. Through a right atriotomy, the entry of the fistula at the RA–SVC junction was identified and oversewn with 4–0 prolene. The atrial septal defect was closed directly. The aneurysm was entered. The fistula was ligated at the posterior aspect of the SVC. The RCA was transected at its aortic origin. The RCA exiting the aneurysm, and the aortic cuff were oversewn with 4–0 prolene. A series of radio frequency maze lesions was created in both atria and the coronary sinus, according to the modified Cox maze pattern described by Hauw Sie [5]. The RIMA was anastomosed to the posterior descending artery. Following warm retrograde reperfusion, de-airing was performed and the cross-clamp released; the heart resumed a junctional rhythm. The patient was weaned from cardiopulmonary bypass using atrioventricular sequential pacing. Intra operative transesophageal ECHO showed normal left ventricular motion, an intact atrial septum and no fistula. Histopathology revealed laminated fibrous tissue with a disrupted elastic lamina and no inflammation or malignancy. The patient remained atrially paced for a few days but subsequently reverted to sinus rhythm. He made excellent progress post-operatively and remained in sinus rhythm 11 months post-operatively.
The incidence of coronary artery aneurysms (CAA) is between 0.3 and 4.9% of patients undergoing coronary angiography, but associated fistulisation into a cardiac chamber is extremely rare. The proximal and middle RCA segments are the commonest sites of CAA [1]. The main causes of CAA include atherosclerosis, congenital and connective tissue disorders, infection, vasculitis, and Kawasaki disease. In our patient, with the absence of specific findings to support one of the above diagnoses, the most likely cause was atherosclerosis. Complications include congestive failure, myocardial infarction, endocarditis, and aneurysm formation with rupture or embolization. Most patients should therefore be considered for surgical correction. Exclusion of the aneurismal segment is necessary to prevent rupture, distal coronary embolization, and competitive flow, which could occlude the graft. Patients with a single communication that is easily dissected usually do not require bypass for suture obliteration. However, a majority of coronary artery fistulae have complex fistulous tracts, and intimate adhesions to the heart, which make dissection and ligation difficult. In such cases, opening the recipient cardiac chamber with the patient on bypass best obliterates the fistula. Westaby et al. [2] mobilized the inflow and outflow and performed an end-to-end anastomosis, instead of aneurysm ligation and coronary bypass. This preserved the native vessel. Interposition vein grafts have also been used to repair CAA [3]. Occasionally direct closure of the fistula with aneurysmorraphy is possible. In most patients with chronic AF, the arrhythmia persists, leaving patients symptomatic even after correction of the underlying structural abnormality [4]. A surgical ablation, such as the maze procedure stands as the only intervention capable of treating the hemodynamic, and thromboembolic sequelae of AF [5]. In patients undergoing complex cardiac repairs, surgeons have been reluctant to expose their patients to prolonged cross-clamp and bypass times and the additional risks of the maze procedure. We used an irrigated radiofrequency ablation device to create all atrial incisions currently used in the Cox maze procedure except for the incisions to enter both atrial cavities. Surgical correction was necessary in this patient, because of the size of the aneurysm, the risk of rupture, the associated fistula and the atrial septal defect. CAAs of at least four times the original vessel diameter are an absolute indication for operation because of their propensity for complications. Our patient had troublesome palpitations secondary to permanent AF and also a transient ischemic attack, necessitating warfarinisation. We therefore performed the radiofrequency maze procedure, and succeeded in abolishing the rhythm and the palpitations. He did not require warfarin subsequently. Simultaneous abrogation of rhythm and organic diseases should be considered not only on the basis of mortality or morbidity but also for improved hemodynamics and quality of life, which are the benefits of the maze procedure [6]. doi:10.1016/S1569-9293(03)00268-8
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| ANN THORAC SURG | ASIAN CARDIOVASC THORAC ANN | EUR J CARDIOTHORAC SURG |
| J THORAC CARDIOVASC SURG | ICVTS | ALL CTSNet JOURNALS |
Top
Abstract
1. Case report
