© 2011 Published by European Association for Cardio-Thoracic Surgery
1FM, GS and PK took part in the care of the patient and contributed equally
to the medical literature search. AM had the supervision report. All authors
approved the final manuscript.
*Corresponding author. Onassis Cardiac Surgery Center, 356 Syggrou Av.,
17674 Athens, Greece. Tel.: +30-210-9493000.
E-mail address: email@example.com (G. Samanidis).
Interactive CardioVascular and Thoracic Surgery 13 (2011) 672-675
Case report - Congenital
Tortuous right coronary artery to coronary sinus fistula
Fotios Mitropoulosa,1, George Samanidisb,1,*, Panagiotis Kalogrisb,1, Alkiviadis Michalisb
aDepartment of Pediatric Cardiac Surgery and Congenital Heart Surgery, Onassis Cardiac Center, Athens, Greece
b2nd Department of Adult Cardiac Surgery, Onassis Cardiac Surgery Center, Athens, Greece
Received 14 July 2011; received in revised form 18 August 2011; accepted 19 August 2011
We are reporting the successful surgical treatment of a 23-year-old female with a giant right coronary artery to coronary sinus fistula. This
woman had complaints of chest pain and dyspnea on exertion for few months. Transthoracic echocardiography (TTE) showed a large tortu-
ous right coronary artery and a dilated coronary sinus. Preoperative multi-detector computed tomography (MDCT) coronary angiography and
cardiac catheterization confirmed the diagnosis of a right coronary artery to coronary sinus fistula. The patient underwent surgical closure
of the fistula and division of the communication between the right coronary artery and the coronary sinus with the use of cardiopulmonary
bypass. The patient was discharged home on postoperative day 5 and at one-year follow-up is symptom-free.
© 2011 Published by European Association for Cardio-Thoracic Surgery. All rights reserved.
Keywords: Coronary artery fistula; Coronary sinus; Congestive heart failure; Transthoracic echocardiography
Coronary artery fistula (CAF) is the most common coro-
nary arterial malformation but is generally a rare cardiac
anomaly. Congenital fistulous connection of the coronary
artery into a cardiac chamber or major vessel often causes
a marked dilation of the donor coronary artery leading to
Conventional angiography is the golden standard of
diagnosing this abnormality. The recent development of
electrocardiographically gated multi-detector computed
tomography (MDCT) coronary angiography has allowed
accurate and non-invasive depiction of coronary artery
diseases and malformation.
The most frequent symptoms and fistula-related complica-
tions are dyspnea on exertion, palpitations, congestive heart
failure, myocardial infarction, infective endocarditis and
death . Surgical closure of the CAF is indicated to prevent
progressive congestive heart failure, endocarditis, coronary
aneurysm formation with rupture or embolization, and when
left to right shunt (Qp/Qs) is >1:1.5 in asymptomatic patients.
We describe the case of a female who underwent success-
ful surgical treatment of a severely enlarged tortuous right
coronary artery (RCA) with a fistula draining into the coro-
nary sinus (CS).
2. Case report
A 23-year-old female patient was admitted to our hospital
with chest pain and dyspnea on exertion for the past 12
months. Her vital signs were unremarkable. Transthoracic
echocardiography (TTE) showed dilation of the proximal
and middle portion of the RCA as well as an anomalous ves-
sel-like structure around the CS. The left ventricular ejec-
tion fraction (LVEF) was 60% with no valvular abnormalities.
Cardiac catheterization showed a dilated tortuous RCA with
communication to the CS (Fig. 1a). It was unclear if there
were one or more points of communication. Further imag-
ing with MDCT coronary angiography, showed a dilated RCA
connecting to a giant CS (Fig. 1b,c).
In this case, indications for surgery included a symptom-
atic patient, large CAF characterized by the hemodynami-
cally significant shunt, significant aneurysmal formation
from RCA and a giant CS.
The surgical approach to the heart was achieved via a
bilateral submammary skin incision and median sternotomy.
The intraoperative findings were a dilated tortuous RCA
with communication to the CS. Therefore, the heart was
arrested and the distal RCA was dissected and opened lon-
gitudinally at its bifurcation and the communication points
were identified from inside (Fig. 2a,b). This was double
ligated and divided with 4/0 prolene proximal to the RCA
and distally to the CS. Cross-clamp time and cardiopulmo-
nary bypass time were 60 min and 70 min, respectively. The
postoperative course was uneventful and the patient was
discharged home in an excellent condition on postoperative
day 5. At one-year follow-up she is asymptomatic, and the