Coronary To Pulmonary Artery Fistula: Surgical Management Using A Pump Assisted Beating-Heart Technique

Background: Coronary arteriovenous fistulae (CAVF) are rare anomalies with an incidence of 0.002% in the general population.The majority of CAVF drain into adjacent structures such as the pulmonary artery, coronary sinus, or the superior vena cava (SVC).Patients can remain asymptomatic or can present with dyspnea, fatigue, and angina.Serious complications include pulmonary hypertension, congestive heart failure, coronary steal, endocarditis, myocardial ischemia, thrombosis, or rupture of the fistula. Case presentation:A 59-year-old male presented to the emergency room with chest pain.He was diagnosed with a NSTEMI and underwent cardiac catheterization that demonstrated severe coronary artery disease (CAD) and a left coronary artery to pulmonary artery fistula.CT angiography (CTA) revealed a large cluster of small vessels abutting the anterior wall of the right ventricular outflow tract (RVOT) with communication and connection of the artery and its cluster to the proximal left anterior descending (LAD) artery.The patient developed further chest pain with EKG changes concerning for a STEMI.The decision was made to proceed with urgent coronary artery bypass grafting (CABG) and fistula ligation using a pump-assisted beating-heart technique.CABG was performed to the LAD, OM1 and posterolateral branch of RCA.Ligation of the fistula was achieved with a Teflon felt mattress pledgetted 3-0 prolene suture.The pump assist technique allowed optimal visualization and elimination of the fistulous communication after ligation with real-time assessment of the ST-segments.The hospital course was uneventful with normalization of the electrocardiogram postoperatively.Conclusion: CAVF continues to be a rare but serious anomaly requiring surgical intervention to relieve symptoms.We believe that our pump assisted beating heart technique optimizes visualization during surgery and helps in ensuring complete elimination after ligation of the fistula with real-time assessment of hemodynamics and STsegments during the procedure.