Epicardial 15-MHz Echocardiography for Effective Repair of Coronary Arteriovenous Fistula Masashi Komeda, MD, PhD, Hirotomo Uchiyama, MD, Sakurako Nakamura,

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Epicardial 15-MHz Echocardiography for Effective Repair of Coronary Arteriovenous Fistula Masashi Komeda, MD, PhD, Hirotomo Uchiyama, MD, Sakurako Nakamura, MD, Takashi Kusunose, MD, Shoji Fujiwara, MD, Toshimi Ujiie, MD, PhD The Annals of Thoracic Surgery Volume 105, Issue 1, Pages e41-e43 (January 2018) DOI: 10.1016/j.athoracsur.2017.09.011 Copyright © 2018 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 Intraoperative view of coronary arteriovenous fistula, its occlusive procedures, and an echocardiography probe with a stabilizer. The fistula was identified or dissected from the fat tissue on the right/left ventricle or main pulmonary artery (mPA). A stabilizer (Stb) for coronary bypass grafting was positioned on the surface of the heart just adjacent to the fistula. A thick, soft pad (Pad) for performing echocardiography was placed to the surface of the fistula, and the 15-MHz echocardiographic (Echo) probe was positioned on the pad for imaging the fistula and its blood flow. Then, 4-0 polypropylene sutures were placed around the fistula. If the fistula was bulky, pledgetted sutures were used to sandwich it. The suture near the origin of the coronary artery was passed through the occluder. After the temporary “occlusion test” was passed, the sutures were tied and the fistula was obliterated. If echocardiography confirmed remnant shunt flow in the fistula, another suture was applied. These procedures were repeated until no blood flow was seen in the fistula. (Ao = ascending aorta.) The Annals of Thoracic Surgery 2018 105, e41-e43DOI: (10.1016/j.athoracsur.2017.09.011) Copyright © 2018 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 Echocardiogram in a representative patient before and after the coronary fistula was ligated. (Left) White arrows show the blood flow in the fistula before its adjacent segment was ligated. (Right) The blood flow (ie, shunt flow) was absent after ligation. The fistula in the area had been obliterated. The Annals of Thoracic Surgery 2018 105, e41-e43DOI: (10.1016/j.athoracsur.2017.09.011) Copyright © 2018 The Society of Thoracic Surgeons Terms and Conditions