Optimal Operative Strategies in Repair of Giant Coronary Artery Aneurysms: Case Presentation

Surgical exclusion of giant coronary artery aneurysms (GCAAs) complicated by coronary-to-left ventricular (LV) fistulae requires a definitive strategy to obliterate the abnormal communication while maintaining myocardial integrity. We report 2 surgical cases focusing on internal orifice closure.

In Case 1 (80-year-old male), a calcified left circumflex artery-GCAA was managed by direct internal closure of the aneurysm neck and LV fistula. The procedure focused on isolating the aneurysm from the coronary circulation, with an auxiliary left internal thoracic artery-obtuse marginal (LITA-OM) graft to ensure distal flow. In Case 2 (39-year-old male), the extensive GCAA required a Hemashield patch (GETINGE, Göteborg, Sweden) for internal closure of the left coronary ostium. Simultaneously, the LV fistula was closed from within the aneurysm. Although postoperative LV unloading via percutaneous cardiopulmonary support (PCPS) and Impella (Abiomed, Danvers, MA, USA) was required, the core surgical success was achieved through complete internal exclusion of both the fistula and the coronary inlet.

For GCAAs with LV fistulae, the primary surgical objective should be the integrated internal closure of the fistula and the coronary ostium. This approach effectively excludes the aneurysm and prevents recurrence.