Left circumflex artery aneurysm with fistula to the coronary sinus
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CASE REPORT
Left circumflex artery aneurysm with fistula to the coronary sinus Reiko Kemmochi1 · Yuki Ohga1 · Youji Kubo1 · Mitsuaki Matsumoto1 Received: 10 May 2019 / Accepted: 6 November 2019 © The Japanese Association for Thoracic Surgery 2019
Abstract A giant coronary artery aneurysm with arteriovenous fistula is a unique pathology having few surgical reports. An 82-yearold woman presented with a symptomatic giant left circumflex artery aneurysm with a fistula to the coronary sinus. The left coronary artery was dilated, and an aneurysmal change was visible from the left main trunk to the fistula. Surgery was performed to close the fistula and seclude all parts of the aneurysmal coronary artery. All coronary branches emerging from the aneurysm required bypass grafting. Herein, we present the history of this unusual case and our successful surgical strategy. Keywords Coronary artery aneurysm · Coronary artery fistula · Surgical strategy
Introduction Coronary artery fistula (CAF) is an uncommon congenital abnormality, with 10% of cases accompanied by a coronary artery aneurysm [1]. A left circumflex artery (LCx) to a coronary sinus fistula with a giant aneurysm is exceedingly rare, and the treatment strategy varies according to the different pathological conditions.
Case report An 82-year-old woman presented to our hospital with a history of rest angina and palpitations. Electrocardiography revealed no signs of ischemia but exhibited atrial fibrillation. Chest roentgenography showed cardiomegaly and pulmonary congestion. Normal wall motion with an ejection fraction of 72% and moderate mitral valve regurgitation due to annular dilation were indicated in the transthoracic echocardiogram. Coronary angiography revealed a giant aneurysm arising from the LCx but did not provide detailed information. Multi-detector computed tomography (MDCT) revealed a dilated and tortuous left coronary artery with a 40-mm aneurysm (Fig. 1a, b). The distal side drained into * Reiko Kemmochi [email protected] 1
Department of Cardiovascular Surgery, Cardiovascular Center, Tsuyama Chuo Hospital, 1756 Kawasaki, Tsuyama 708‑0841, Okayama, Japan
the coronary sinus (Fig. 1c). The left anterior descending artery (LAD), high lateral branch (HL), obtuse marginal branch (OM), and posterolateral branch (PL) separated from the dilated and aneurysmal left coronary artery with normal diameters. Right heart catheterization data were as follows: pulmonary blood flow to systemic blood flow ratio of 1.75; mean pulmonary arterial pressure of 30 mmHg; and right ventricular end-diastolic pressure of 6 mmHg. Myocardial scintigraphy did not detect ischemia. An operation was performed via median sternotomy with cardiopulmonary bypass. The aneurysm was flexible but with scattered calcification. Coronary artery bypass grafting to the LAD, HL, OM, and PL was performed with saphenous vein grafts (SVGs) on the beating heart. Two proximal anastomoses were made in advance with a partial aortic clamp, after which all distal anastomoses were done. The dist
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