Surgical management of symptomatic coronary artery fistulae in the adult.

We describe the surgical management of adult symptomatic coronary artery fistulae. The technique is a fundamental approach entailing cardiopulmonary bypass and cardiac arrest with the goal of fully identifying the epicardial course of the coronary fistulae as well as that of the intrapulmonary artery ostial shunt. The more accurate the localization of these primary components of the fistulous tract, the more precise and successful is the ligation of the aberrant coronary connections. This result subsequently enhances the successful surgical obliteration of the symptomatic left-to-right shunt inherent in these congenital coronary fistulae that may not manifest symptoms until adulthood. With conventional cardiopulmonary bypass, myocardial protection and arrest, the main pulmonary artery is opened between the pulmonary valve and its bifurcation. Additional antegrade cardioplegia is administered, and the ostial connection of the coronary fistulae can be identified in the wall of the main pulmonary artery and internally ligated. After this, the epicardial course of the coronary fistulae can be identified and doubly ligated as close as possible to the native coronary from which they originate as well as their approximate external connection to the main pulmonary artery.