Traumatic Coronary Artery Fistula in a Child
An 8-year-old boy with an insignificant medical history presented to our institution after a motor vehicle accident that resulted in the deaths of his two siblings. He arrived in the emergency department hypotensive and unconscious. On initial evaluation, a heart rate of 174 bpm, blood pressure of 98/46 mm Hg, and agonal respirations were observed. He was immediately intubated and fluid-resuscitated. Work-up revealed diffuse axonal injury with right frontal cerebral contusion, bilateral femur fractures, and bilateral humerus fractures. He had no penetrating chest wall injuries. He underwent extensive orthopedic surgery. Trauma management did not include the use of a pulmonary artery catheter. On hospital day 12, the patient was noted to have a new continuous murmur. Transthoracic echocardiography revealed a very small coronary artery–right ventricle fistula (CAF). On hospital day 14, the patient was discharged. Follow-up transthoracic echocardiogram demonstrated interval enlargement of the left main coronary artery. Three months later, the patient underwent a cardiac catheterization that confirmed a traumatic CAF of the left anterior descending (LAD) artery into the right ventricle with normal ventricular function (Figure 1). Oximetry and Fick calculations estimated a 1.3:1 left-to-right shunt. One month after his heart catheterization, he presented for definitive repair. After induction of anesthesia, transesophageal echocardiography confirmed a CAF from the LAD into the right ventricle, normal overall function, and a small left-to-right shunt (Figure 2). Cardiopulmonary bypass was initiated and the heart was arrested. The anterior aspect of the dilated LAD was opened, revealing a 2.5-mm communication with the right ventricle. This defect was primarily closed. The arteriotomy was then primarily closed. Postoperative recovery was unremarkable. The patient is asymptomatic at 6 months’ follow-up.