[Anesthetic management in a patient complicated with left coronary artery-left ventricular fistulae]

We have experienced anesthetic management for posterior lumbar interbody fusion in a 76-year-old female with left coronary artery-left ventricular fistulae. She was admitted to our hospital because of chest pain and was found to have left coronary artery-left ventricular fistulae 6 months before this operation. The electrocardiogram at rest showed T-wave inversions in leads V3-V6. Selective coronary angiography showed the contrast medium streaming into the left ventricle via a maze of fine vessels from the distal left anterior descending coronary artery. Cardiac catheterization revealed left ventricular end-diastolic pressure of 30 mmHg and mean pulmonary capillary wedge pressure of 16 mmHg. Anesthesia was induced with intravenous propofol 60 mmHg, fentanyl 0.1 mg and vecuronium 6 mg, and maintained with 50% nitrous oxide and isoflurane (0.5-1.5%) in oxygen with meticulous intravenous administration of fentanyl. Cardiac function was evaluated with Swan-Ganz catheter during anesthesia. Dopamine and prostaglandin E1 ware continuously infused intravenously to decrease high afterload and maintain cardiac output. The operative and post-operative courses were uneventful. Coronary artery-left ventricular fistulae are extremely rare and can cause myocardial ischemia from coronary steal. A careful management with meticulous anesthetic care is emphasized for patients with coronary artery-left ventricular fistulae.