Treatment of high-output coronary artery fistula by off-pump coronary artery bypass grafting and ligation of fistula

Coronary artery fistulas (CAF) are uncommon entities often associated with myocardial ischemia and high output failure. Surgical options include ligation of the fistula, with/without simultaneous coronary artery bypass grafting (CABG). We report a case of left main coronary artery (LMCA) fistula to the coronary sinus (CS), which was associated with high-output bi-ventricular failure, and moderate mitral (MR) and tricuspid regurgitation (TR), related to the volume overload and annular dilatation. This was tackled elegantly by off-pump CABG to protect the territories supplied by the LMCA, followed by ligation of the fistula. This resulted in resolution of the MR and TR. Intraoperative transesophageal echocardiogram (TEE) greatly facilitated the surgical treatment, by identifying the origin and the draining points for the fistula, and aided in the quantification of MR and TR, which had regressed sufficiently at the end of the procedure and did not require surgical correction. This article outlines the importance of multi-disciplinary treatment approach for this complex condition.