Late Thrombosis With Ischemia After Left Main Coronary Artery Fistula Closure: When Simplified Repair Is Not Enough
Vivek Mehta1, Richard Tenure2, Robert Rahmani3
1Department of Cardiovascular Surgery, Northwell Health, Manhasset, New York, USA.
Insights
This case report details a rare left main coronary artery to right atrial fistula in a patient with Factor VII deficiency. Surgical closure posed a dilemma between safety and definitive repair, leading to a later coronary aneurysm.
Area of Science:
- Cardiovascular Surgery
- Congenital Heart Disease
Background:
- Coronary artery fistulae are rare anomalies (<0.2% of congenital cardiac malformations).
- Surgical closure is standard for complex or high-flow fistulae.
Background:
Coronary artery fistulae are rare congenital or acquired anomalies, comprising <0.2% of congenital cardiac malformations. Surgical closure is the gold standard for complex or high-flow fistulae, typically via direct chamber closure or tract ligation.
Case Summary:
We report a left main coronary-to-right atrial fistula in a patient with Factor VII deficiency. Given the deep intramediastinal course and heightened bleeding risk, we performed right atrial egress patch closure with mid-fistula ligation rather than extensive resection. Although this strategy minimized operative complexity, the patient later developed a left main coronary aneurysm with late thrombosis, raising concern that a more aggressive initial repair may have reduced long-term risk.
Discussion:
This rare presentation highlights the surgical dilemma between procedural safety and definitive repair.
Take-Home Messages:
Operative planning must balance bleeding risk against durable reconstruction. The management of residual coronary aneurysms after fistula closure remains uncertain.
