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.