Description
A 19-year-old man was admitted for exertional dyspnea and oppressive chest pain. A diastolic murmur could be heard at the left border of sternum. Chest radiography and electrocardiography revealed no abnormalities. Cardiac troponin-I was normal. Transthoracic echocardiography (TTE) demonstrated a large vascular structure emptying into the left ventricle (LV) (Figure1 A). The fistulous fistula was located near the posterior mitral annulus, with diameter of 0.5cm. The peak velocity of the shunt was 2.9 m/s. Computed tomography angiography (CTA) revealed a 8-cm long left circumflex coronary aneurysm with a fistula to the posterior wall of left ventricle (Figure1 B, D, E). The fistula originated from the left coronary artery and meandered on the surface of heart. The diameter of the wider part was 1 cm. It ran along the left atrioventricular groove to the posterior atrioventricular junction. Coronary angiography showed a highly enlarged left circumflex coronary artery which entered the left ventricle at the posterior side (Figure1 C).
The operation was performed under cardiopulmonary bypass and the heart was arrested with the cold blood cardioplegia (Figure1 F). The aneurysm sac was opened and explored, and the fistulous orifice to the LV was sutured and ligated with 4-0 prolene sutures. The remainder of the fistulous vessel was reconstructed with a running 4-0 prolene suture. The postoperative TTE and CTA showed the fistula was closed with a little residual intracardiac shunt due to collateral circulation (Figure1 G-I). The patient recovered well and was discharged with no symptoms.