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Systemic Artery-to-Pulmonary Artery Fistula Mimics Perioperative Myocardial Infarction During Coronary Bypass Grafting
Woosik Han, Kang Min Kim, Seung Ri Kang.
Chung-ang University Gwang-myeong Hospital, Gwangmyeong, Korea, Republic of.
Objective: A systemic artery to pulmonary artery fistula is a rare condition, often diagnosed incidentally as many patients are asymptomatic initially. Perioperative myocardial infarction (MI) is a serious complication that may occur during coronary artery bypass graft (CABG) surgery. This report presents a case where a bronchial artery to pulmonary artery fistula was found incidentally during CABG, mimicking perioperative MI.
Methods: A 58-year-old male underwent CABG for unstable angina with left main disease. Following bilateral internal mammary harvesting and systemic heparinization, the patient's blood pressure dropped, and pulmonary artery pressure (PAP) increased significantly. Sudden massive bloody secretions were observed from the endotracheal tube, accompanied by a drop in oxygen saturation. Emergent cardiopulmonary bypass (CPB) was established due to suspected perioperative MI. Although hypotension and hypoxia improved after initiating CPB, the high PAP and continuous, massive hemoptysis persisted. CABG was completed while on CPB. Transit time flow measurements (TTFM) for all grafts were satisfactory, but we could not wean the patient off CPB due to persistent high PAP and hemoptysis.
Results: CPB was converted to extracorporeal membrane oxygenation (ECMO), and the patient was transferred to a hybrid room for evaluation of hemoptysis. An angiogram revealed a bronchial artery to pulmonary artery fistula <Figure 1>, which was then treated with glue embolization. Following the embolization, hemoptysis ceased, and PAP returned to near-normal levels. The patient was weaned off ECMO on the 7th postoperative day and discharged on the 20th postoperative day without complications.
Conclusions: A preoperatively undiagnosed bronchial artery to pulmonary artery fistula can behave like perioperative MI during surgery. Preoperative enhanced chest computed tomography may help prevent unexpected catastrophic intraoperative events due to undetected systemic artery to pulmonary artery shunts.
<Figure 1>
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