Interact CardioVasc Thorac Surg 2005;4:81-82. doi:10.1510/icvts.2004.097865
© 2005 European Association of Cardio-Thoracic Surgery
Case report - Cardiac general |
A fistula between the circumflex artery and the coronary sinus mimicks coronary artery disease in a 63-year-old woman
Wolfgang Bothe1,
Christian Schlensak1,
Andreas van de Loo2 and
Friedhelm Beyersdorf1,*
1 Department of Cardiovascular Surgery, University of Freiburg, Freiburg i. Br., Germany
2 Department of Cardiology, University of Freiburg, Freiburg i. Br., Germany
Received 10 September 2004;
received in revised form 22 December 2004;
accepted 23 December 2004
*Corresponding author: Department of Cardiovascular Surgery, University of Freiburg, Hugstetter Strasse 55, 79106 Freiburg, Germany. Tel.: +49-761-270-2818; fax: +49-761-270-2550 .
E-mail address: beyers{at}ch11.ukl.uni-freiburg.de (F. Beyersdorf).
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Abstract
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A 63-year-old woman presented with angina and shortness of breath (NYHA III). Selective coronary angiography revealed a gross AV-fistula between the circumflex artery and the coronary sinus. The patient underwent operative closure of the fistula and was discharged home without symptoms.
Key Words: Coronary anomaly; Coronary artery disease; Heart surgery
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1. Case report
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A 63-year-old woman presented with a short history of worsening angina and shortness of breath (NYHA III). She had been previously healthy and was only being treated for arterial hypertension. ECG was without pathological findings. Selective coronary angiography revealed a gross, aneurysmatic AV-fistula between the circumflex artery and the coronary sinus (Fig. 1a). Contractile function was normal (ejection fraction: 66%). Arterio-venous shunting was determined by additional Swan-Ganz catheterization and oximetry. The measurements revealed a left-to-right shunt of 0.55 (Qp:Qs=1.8:1). Cardiac Index was 3.6 l/min/m2. Fig. 2 shows the fistula in situ. The fistula was closed by incising the distal part of the aneurysm and sewing a pericardial patch over the opening of the fistula into the coronary sinus using cardiopulmonary bypass with cardioplegic arrest. The circumflex artery was not a suitable target for a bypass. Fig. 1b shows the coronary angiogram eight weeks after surgery in which there is no longer a connection between the circumflex artery to the coronary sinus. Postoperative course was uneventful. The patient was discharged home with a significant improvement of symptoms (NYHA I) eight days after the operation.
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Fig. 1. (a) Preoperative angiography of the left coronary artery in right anterior oblique projection. The arrow indicates the circumflex artery draining into the coronary sinus (CS). Note the dilatation of the proximal circumflex artery and the haziness of the dye, indicating high flow rates through the fistula. Ao indicates aorta, RA indicates right atrium. (b) Postoperative angiography of the left coronary artery in left anterior oblique projection. The arrow points to the circumflex artery. Note the absence of a direct connection to the coronary sinus. Also note the clearer image due to a higher concentration of contrast medium, suggesting significantly reduced flow, compared to the preoperative image.
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Fig. 2. Intraoperative presentation of the AV-fistula before its closure. The arrows point to the fistula. LV indicates the location of the left ventricle under the surgeon's hand, DI indicates diaphragm.
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Abstract
1. Case report