Massive Aneurysmal Coronary Artery Fistulae Demonstrating the Continued Utility of Surgical Intervention

Coronary artery fistulae (CAF) are rare aberrant connections between coronary arteries and the great vessels, coronary sinus, or cardiac chambers. Although most CAF are asymptomatic, patients with large, hemodynamically significant, or symptomatic fistulae might benefit from closure. Transcatheter occlusion is usually the preferred approach given that it avoids a sternotomy and cardiopulmonary bypass. However, there remain CAF with challenging features such as tortuous anatomy, large aneurysms, and concomitant cardiac disease that benefit from surgical ligation. We present 3 cases of CAF, all of which were treated by surgical ligation because of their hemodynamic and clinical significance, tortuosity, and massively dilated aneurysms. These cases illustrate the heterogeneous presentations of CAF and the varied open approaches to closure: epicardial versus intracardiac closure and with or without ligation of the involved coronary artery and distal revascularization. We present high-resolution 3-dimensional reconstructions of these impressively large fistulae and discuss the need for surgical consideration in similar cases.