Identification of the Site of Drainage of Left Main Coronary Artery to Right Atrium Fistula With Intraoperative Transesophageal Echocardiography

摘要

Coronary artery fistula (CAF) is an infrequent vascular anomaly that establishes a direct link between a large subepicardial coronary artery and a cardiac chamber, major vessels, or other vascular structures. Although coronary arteriography remains the gold standard for the diagnosis of CAF, it is not always possible to reveal the complete delineation of CAF including its origin, course, and drainage. A case of left main CAF originating directly from the aorta is reported in which preoperative coronary arteriography failed to identify the site of drainage and intraoperative transesophageal echocardiography (TEE) was used to identify the precise location of drainage. Scheduled surgical repairs included closure of the origin of the CAF (the left main coronary orifice from the aorta) and closure of the drainage of the CAF combined with coronary artery bypass graft (CABG) surgery to the left anterior descending artery and the circumflex artery. In this particular case, the left anterior descending artery and the circumflex artery were not scheduled for closure at their origins from the left main CAF to keep the circulation available for the other feeding arteries to the left ventricle (LV) that might originate from the CAF. Therefore, intraoperative TEE was also essential for confirmation of absence of fistulous flow and regional wall motion abnormalities of the LV.