Surgical treatment for a case of coronary steal from a traumatic coronary artery-cameral fistula after blunt cardiac injury.

INTRODUCTION: Blunt cardiac trauma covers a spectrum of injuries from clinically insignificant myocardial contusions to lethal ruptures of cardiac valves and chambers. Traumatic coronary artery-cameral fistulas (TCAF) are a rare sequelae of blunt chest trauma.

CASE PRESENTATION: A 53-year-old male developed a TCAF after a motor vehicle collision. He was found on admission to be in cardiogenic shock with an elevated troponin and intermittent bifascicular block. An echocardiogram revealed hypokinesis of the mid-anteroseptal myocardium with an ejection fraction of 50%. Cardiac catheterization revealed a pseudoaneurysm of the left anterior descending artery (LAD) with a fistulous connection to the right ventricle, shown to be associated with reversible anterior wall ischemia from distal LAD coronary steal phenomenon on a nuclear perfusion scan. Given the ischemic burden, he was treated with operative revascularization via a single vessel coronary artery bypass graft (CABG) using the left internal mammary artery to LAD.

DISCUSSION: Early repair of TCAF can halt the progression of complications like left-to-right shunting, pulmonary hypertension, and heart failure. The two best described operative approaches to surgical closure of the fistula are either via external ligation or direct repair from within the recipient chamber, possibly with bypass grafting distal to the fistula site. Transcatheter closure and conservative management has been described for select patients with iatrogenic fistulas in recent literature.

CONCLUSION: High levels of clinical suspicion are necessary for the early detection and intervention of TCAF. Surgical or transcatheter interventions including fistula ligation and CABG can prevent later complications of heart failure.