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eComment. Surgical management of coronary-to-pulmonary artery fistulas.

Yamamoto and colleagues have described the successful surgical treatment of a patient with bilateral coronary-to-pulmonary artery fistulas [1]. 
 
We agree with their decision of opening the main pulmonary artery (PA) under CPB and closure of both orifices with a suture [1]. 
 
We reported this additional manoeuvre of opening the PA for the direct identification of the entry points of all the fistulas into the PA plus the securing of its closure with a patch of autologous pericardium, sealed with Bioglue for the avoidance of recurrence and it seems to be a very helpful technique [2]. 
 
Biorck and Crafoord, on the 22nd of July 1946, in the Surgical Clinic I at Sabbatsberg Hospital in Stockholm, performed the first successful surgical ligation of a pulmonary-to-coronary artery fistula. The patient was a 15-year-old male who was referred due to exertional dyspnoea, fatigue and a ‘continuous’ murmur over the pulmonary area. The primary diagnosis after radiographic and phonocardiographic findings was of a case of patent ductus arteriosus Botalli [3]. 
 
For this reason the patient underwent left postero-lateral thoracotomy by the method of Crafoord (according to the authors) with a removal of the fifth rib [3]. 
 
However, in the area of ductus arteriosus no thrill was palpable and further exploration revealed an arteriovenous aneurysm on the PA which was consistent with an arteriovenous communication between an aneurysm of an aberrant branch of the left coronary artery and the PA [3]. 
 
The authors applied and tightened a silk ligature for 3–4 minutes around the abnormal artery centrally to the aneurysm for observation of the reaction of the heart. No abnormalities in the cardiac function were noted and the silk ligature was tied. On direct auscultation with a sterile stethoscope the murmur had then decreased significantly. The authors applied another silk ligature distally now to the aneurysm and, thereafter, the continuous murmur disappeared. The pericardium and chest were closed with no drains and the patient had an uneventful recovery with significant improvement in his functional status (no dyspnoea on moderate exertion) when he was reviewed in November 1946 [3]. 
 
According to Angelini and colleagues, coronary artery anomalies (including coronary arteriovenous fistulas) appear quite frequently in the practice of cardiologists and cardiac surgeons. In addition, the coronary artery anomalies display a variety of anatomic variants, sizes, and clinical symptoms with different implications in all spectrums of ages [4]. 
 
It is very important to bear in mind that, according to the Sudden Death Committee of the American Heart Association, a 19% of deaths in athletes is related to coronary artery anomalies [5]. 
 
The multidisplinary approach is of paramount importance for all these patients. The type of treatment of most of the subgroups of coronary artery anomalies is not supported by evidence-based guidelines [4]. 
 
A careful assessment is needed to clarify who of those patients should be under close follow-up and who will be treated in the catheterization laboratory (use of vascular plugs, umbrella devices, covered stents or coils) or in the theatre (TOE, on/off CPB, plus/minus CABG). 
 
Conflict of interest: none declared.