CORONARY-ARTERY FISTULAS IN INFANTS AND CHILDREN - A SURGICAL REVIEW AND DISCUSSION OF COIL EMBOLIZATION

Background. Coronary artery fistula (CAF) is a rare congenital anomaly that can be complicated by intracardiac shunts, endocarditis, myocard ial infarction, or coronary aneurysms. Recent reports have emphasized the efficacy of percutaneous transcatheter techniques. The purpose of this article is to review a 28-year surgical experience with CAF as a standard for comparison and to discuss the emergence and efficacy of t ranscutaneous catheter coil embolization as an alternative form of the rapy. Methods. From 1968 to 1996, 17 patients (age, 6 weeks to 16.5 ye ars; mean age, 5.5 years) were diagnosed with CAF: 8 of 12 by echocard iography and 17 of 17 by cardiac catheterization. All patients with is olated CAF (n = 13) were asymptomatic despite significant clinical, el ectrocardiographic, and chest roentgenographic findings in 10. Sixteen had congenital CAF and 1 had acquired CAF after tetralogy of Fallot r epair with injury of the anomalous left anterior descending coronary a rtery. Associated anomalies included tetralogy of Fallot (2), atrial s eptal defect (1), and patent ductus arteriosus (1). Nine fistulas orig inated from the right coronary artery and eight from the left. Drainag e was to the right ventricle (9), right atrium (4), pulmonary artery ( 3), and left atrium (1). Results. All patients had a median sternotomy with epicardial or endocardial ligation. Cardiopulmonary bypass was u sed in 8; 1 of these (iatrogenic CAF) required distal internal mammary artery bypass graft. There were no operative or late deaths. Follow-u p evaluation by physical examination (17), echocardiography (8), and c atheterization (2) showed no evidence of recurrent or residual CAF. A retrospective review of the 16 available cine cardioangiograms showed that coil embolization was possible in, at most, 6 patients. Conclusio ns. Early surgical management of CAF is a safe and effective treatment resulting in 100% survival and 100% closure rate. Transcatheter embol ization is a reasonable alternative to standard surgical closure in on ly a very small, select group of patients. These surgical results shou ld be considered the standard against which transcatheter techniques a re compared. (C) 1997 by The Society of Thoracic Surgeons.