Transesophageal echocardiography, more than a diagnostic tool: use during surgical ligation of coronary artery fistulae - a case report

Abstract

Coronary artery fistulae (CAF) are an infrequent coronary abnormality. Herein, we describe the use of intraoperative transesophageal echocardiography (TEE) in the treatment of CAF. A 61 year-old woman presented with chest pain and symptoms consistent with unstable angina. Subsequent coronary angiography revealed the presence of 2 CAF, one extending from the left anterior descending artery to the pulmonary artery (PA) and the other extending from the proximal right coronary artery to the PA. Surgical ligation of the CAF without coronary bypass was arranged. Intraoperative TEE was successfully employed to localize the CAF, monitor fistula blood flow and heart wall motion, and confirm successful ligation. The patient recovered without complications. This case highlights the utility of intraoperative TEE during ligation of CAF.

Figures

Figure 1

From the ME AV LAX view, right coronary cusp of aortic valve can be easily figured while RCA is seldom visualized (A). However, the abnormal RCA-to-PA fistula of this patient was observed (diameter = 0.4 cm) because of the proximity of the fistula to the RCA origin (B). Mid-esophageal aortic valve long axis-view. NCC: noncoronary cusp, RCC: right coronary cusp, RVOT: Right ventricular outflow tract, RCA: right coronary artery, PA: pulmonary artery.

Figure 2

From the ME AV SAX view, the orifice of LAD-to-PA fistula was not found in the beginning. The LAD artery to PA fistula (diameter = 0.5 cm) was partially visualized (A); after tracing down to the LM with the view transition from SAX to LAX, the LAD-to-PA fistula was fully visualized with 0.5 cm in diameter by tracing the vessel during transition from the ME AV SAX view to the ME AV LAX view (B, C, D). Mid-esophageal aortic valve short-axis view, LA: left atrium, LM: left main coronary, LV: left ventricle, LVOT: left ventricular outflow tract.