Coronary left ventricular outflow tract fistula after resection of a subaortic valve membrane

Excerpt

A 34-yr-old woman was admitted to hospital for resection of a subaortic valve membrane and repair of an ascending aortic aneurysm (Figs. 1 and 2). At 8 months of age, the patient underwent resection of a subaortic valve membrane and closure of a patent ductus arteriosus. On this occasion, the patient underwent resection of the subaortic membrane, ventricular myomectomy, and replacement of the ascending aorta with an aortic valve-sparing technique. At the end of surgery, after unclamping the aorta, a small, central aortic insufficiency grade 1/4 was observed, with no ventricular septal defect. The mitral valve was normal, but an unusual subaortic color Doppler flow was discovered (Fig. 3), which had not been present preoperatively. This color flow was diastolic and appeared to originate from a branch of the left anterior descending (LAD) coronary artery draining into the left ventricular outflow tract (LVOT) just inferior to the aortic valve (Video 1, mid-esophageal inflow-outflow view). Pulsed-wave Doppler confirmed the typical diastolic flow pattern of the LAD coronary artery (Fig. 4). A fistula from a perforator septal branch of the interventricular septum was presumed to have been responsible for this unusual color flow (also known as a truncated septal perforator). This fistula was not present on the preoperative coronary angiogram. Weaning from bypass was easy and the left segmental ventricular function remained normal. The surgeon decided not to intervene on this new finding, and the patient had an uneventful recovery.

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