Right Coronary Aneurysm with Coronary Arteriovenous Fistula to Right Atrium

A 56-year-old man presented with shortness of breath and palpitations. Workup and evaluation revealed paroxysmal atrial fibrillation, severe tricuspid regurgitation, and a giant right coronary aneurysm with an arteriovenous fistula to the right atrium. An echocardiogram revealed an aneurysm of the proximal right coronary artery. Cardiac catheterization and cardiac magnetic resonance imaging showed the aneurysm coursing between the right pulmonary artery and the ascending aorta. The caliber of the right coronary artery distal to the aneurysm was normal.
A median sternotomy was performed and the pericardium was opened to encounter the proximal right coronary aneurysm. The superior vena cava was looped to allow for exclusion of venous return. Direct cannulation of the aorta and percutaneous access of the femoral vein were performed to place the patient on cardiopulmonary bypass. Further dissection revealed the giant aneurysm between the aorta, right pulmonary artery, and superior vena cava, with an apparent arteriovenous fistula between the right coronary aneurysm and the right atrium. The shunted blood flow coursed from the aorta, to the right coronary aneurysm, to the right atrium.
After the heart was arrested and the patient placed on cardiopulmonary bypass, the normal right coronary artery distal to the aneurysm was dissected, allowing for a reverse saphenous vein to be grafted. The right coronary artery between the aneurysm and the graft was ligated. The proximal right coronary artery was further identified and ligated at the aorta. Attention was then turned to the right atrium, which was opened to identify the entry of the arteriovenous fistula. Additionally, the proximal right coronary artery aneurysm sac was opened and followed down through the giant aneurysm to the right atrium. A probe was passed to delineate the flow through the fistula. A bovine pericardium patch was sewn from within the right atrium to close the fistula.
The severe tricuspid regurgitation discovered during preoperative workup was managed with the placement of a tricuspid annuloplasty ring. A left-sided pulmonary vein maze procedure was performed for the atrial arrhythmia, and was accompanied by the placement of a left atrial appendage clip. The proximal vein graft was then anastomosed to the aorta, and the aortic clamp was released. The right coronary aneurysm sac and giant aneurysm were oversewn. The patient was taken off of cardiopulmonary bypass with restoration of normal anatomic blood flow.
In conclusion, this video demonstrates the presentation, diagnosis, and surgical treatment of a large complex right coronary artery aneurysm with an arteriovenous fistula to the right atrium. The surgical treatment was ligation and exclusion of the aneurysm, with coronary artery bypass to the distal right coronary artery, and patch repair of the right atrium. The patient had an uneventful postoperative course with a full recovery.