Treatment options for CAF include

Treatment options for CAF include surgery and catheter closure. Swan et al reported the first successful closure of a fistula from using a cardiopulmonary bypass. Surgery is not free of risk but associated with low morbidity and mortality rates ranging from 0% to 1.4%. Myocardial infarction occurs in < 5% of cases, and a risk of recurrence of the fistula exists. Reidy et al published the first report on percutaneous therapeutic embolization with successful transcatheter fistula occlusion. Catheter closure of fistulae is now considered an effective and safe alternative to surgery. However, it can be complicated by inadvertent coil migration, resulting from high flow in large fistulae or undersized coils, transient T-wave changes, transient bundle branch block, and myocardial infarction. In our patient, the greatest challenges were preventing iatrogenic injury of the normal coronary dna-pkcs and ensuring myocardial protection during cardiac surgery. According to the CT findings, the CAF originated from the LM near the LCx and LAD. To prevent iatrogenic injury of the coronary artery, we marked the LCx and LM with a pen before isolating the CAF. This enabled distinguishing between the normal coronary arteries and the CAF. Next, we created a loop around the CAF and divided it as close to the LM as possible (Figure 2B). This prevented the formation of a sac with a thrombus formation inside. After the CAF was divided and ligated, antegrade blood cardioplegic with low perfusion pressure was administered to determine bleeding at the ligated stump and residual outlet of the RA. We combined blood cardioplegic solution and HTK, because repeated infusion of cardioplegic solutions during a long arrest time interrupts surgical procedures. St. Thomas extracellular solution (Plegisol, Hospira, Inc) based on a high potassium level leads to a rapid arrest of the myocardium. However, it offers limited myocardial protection for patients requiring longer cross-clamp times. It also increases cellular edema and impedes endothelial functions because of the need for repeated perfusion during ischemia. The low level of potassium and absence of calcium in HTK solution have been suggested to be advantageous for organ preservation, but this solution slowly initiates arrest. Based on the advantages and disadvantages of the St. Thomas and HTK solutions, we adapted the protocol to use St. Thomas cardioplegia for achieving an initial quick cardiac arrest and HTK cardioplegia for prolonged myocardial storage. CAFs are known to cause high-output heart failure; this is unlikely to have been the only mechanism of left ventricular dysfunction in our patient, because her cardiac output was within the normal range. A high flow in the fistula possibly resulted in a coronary steal phenomenon with subsequent ischemia and dysfunction of the LV. The theory is that runoff from a comparatively large proximal arterial segment occurs preferentially through a lower-resistance vascular bed (like a fistula), reducing the flow to the higher-resistance nutrient coronary branches. Our patient presented with congestive heart failure, and her LV function recovered after surgery. Therefore, the CAF may not have been the only lesion or a noncontributing factor, but rather contributed to the symptoms of congestive heart failure. CAFs are rare but discovered with increasing frequency because of improvements in imaging. They can cause severe complications warranting treatment. Compared with other open heart surgeries with a normal coronary artery, CAFs lead to a more varied clinical course. Care must be taken in protecting the myocardium. In our patient, surgery was performed under adequate myocardial protection, and the patient had a favorable outcome. In conclusion, CAF treatment with or without other procedures requires close attention and aggressive surgical treatment under adequate myocardial protection, to prevent congestive heart failure and provide sufficient coronary circulation to the heart.