Case Report
A 48-year-old woman was referred to our institution for surgical management of ruptured CAA associated with CAVFs. Four days before referral, she had experienced chest discomfort followed by presyncope. Following medical examination at the neighboring hospital, her condition was diagnosed as cardiac tamponade due to rupture of the CAA with CAVFs. Computed tomography (CT) scan revealed an aneurysmal formation measuring 3.0 × 2.0 cm, which was located at the left anterior aspect of the pulmonary artery trunk with a large amount of pericardial effusion (Fig. 1a). Pericardial drainage was performed and 100 mL of blood was aspirated (Fig. 1b). Subsequently, her symptom improved immediately. Additionally, CT scan revealed that the aneurysm was communicated with the left and right coronary arteries (RCA) through anomalous fistulous vessels that drained into the pulmonary artery trunk (Fig. 1c). Fistulous vessels originating from proximal RCA and left anterior descending artery (LAD) were confirmed by coronary angiography. With the diagnosis of ruptured CAA with CAVFs, operation was urgently performed.
The patient underwent a median sternotomy. Surgical exposure revealed mild fibrous adhesion mainly around the pulmonary artery and a saccular-type mass measuring 3.0 cm in diameter at the left anterior surface of the pulmonary artery (Fig. 2a). Prior to repair of the CAVFs, intraoperative near-infrared fluorescence imaging of CAVFs was performed using photodynamic eye (Hamamatsu Photonics, Hamamatsu, Japan).7 Approximately 15 seconds after intravenous injection of indocyanine green, abnormal fistulous vessels were visualized at the anterior surface of the pulmonary artery (Fig. 3a, 3b). Cardiopulmonary bypass was established between the ascending aorta and bicaval cannulation. Following aortic cross clamping, cardiac arrest was achieved by antegrade cardioplegia. First, the feeding arteries originating from the proximal RCA were ligated at their origin. Second, the pulmonary artery was incised longitudinally and the fistulous opening that communicated between the pulmonary artery and aneurysm was closed with a pledgeted suture (Fig. 2b). The CAA was opened and the drainage sites from the feeding arteries were identified by antegrade infusion of cardioplegia (Fig. 2c). These drainage sites were closed from within the aneurysm followed by aneurysmorrhaphy. Weaning from the cardiopulmonary bypass was uneventful. After completion of surgical repair, no residual CAVFs was confirmed from repeated fluorescence imaging (Fig. 3c). The patient’s postoperative recovery was uneventful and she was discharged 7 days after surgery. Postoperative CT did not reveal any evidence of residual fistulas. Recurrent CAVFs and CAA were not observed during follow-up. Written informed consent was obtained from the patient for the publication of this report.