1. Early Surgical Repair of the Coronary Artery Fistulae in Children: 30 Years of Experience 
Deane Yim, MBChB, FRACP, Matthew S. Yong, MBBS, Yves d’Udekem, MD, PhD, Christian P. Brizard, MD, Igor E. Konstantinov, MD, PhD 
The Annals of Thoracic Surgery 
Volume 100, Issue 1, Pages (July 2015)
DOI: /j.athoracsur
Copyright © 2015 The Society of Thoracic Surgeons Terms and Conditions

2. Fig 1
Cardiac catheterization demonstrating coronary artery fistula. (A) Selective right coronary angiography demonstrates a large right coronary fistula that tapers distally, then widens to an aneurysmal sac before entering into the right ventricle (exit point not shown). (B) Selective injection into the proximal end of the fistula delineates the separate right coronary arterial system.
The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur )
Copyright © 2015 The Society of Thoracic Surgeons Terms and Conditions

3. Fig 2
Schematic representation of the sites of the coronary artery fistulae. (A, B) Fistulae involving right coronary artery (RCA) and (C–C2) isolated left coronary artery (LCA). (A) Fistula from RCA to right atrium (RA [n = 1]) or right ventricle (RV [n = 5]). In 2 children, the aneurysmatic RCA was opened and the fistula to the RV was closed transcoronary with direct suture. The other 3 children had epicardial closure. (B) Fistula from both RCA and LCA to RV (n = 2). Both children had epicardial closure. (C) Fistula from LCA to RA (n = 2) and left atrium (LA [n = 1]). Both LCA to RA fistulae appeared to be enlarged sinoatrial nodal arteries running on the top of both atria and behind aorta with distal opening into RA. One patient had epicardial closure proximally and the other had endocardial closure through the RA. In both patients, the aneurysmatic coronary artery was excised. The fistula to the LA was closed endocardially through the roof of the LA. (C1) Fistula from LCA to RV with intramuscular tunnel (n = 1). The RV muscular tunnel was opened and proximal endocardial closure of the fistula was performed. The tunnel was then obliterated with running suture. (C2) The fistula from LCA to coronary sinus (n = 1) was closed endocardially from the RA through the enlarged coronary sinus.
The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur )
Copyright © 2015 The Society of Thoracic Surgeons Terms and Conditions

4. Fig 3
Examples of three surgical approaches to close the coronary artery fistulae. (A) Epicardial closure was performed in a child with enlarged coronary artery draining into the right atrium (RA) behind the aorta. Contrast injection into the enlarged coronary artery (middle panel) delineated coronary anatomy and demonstrated passage of contrast into the RA. Both entry and exit points were closed and the enlarged coronary artery was resected. (B) Endocardial closure was performed in a child with fistula opening into the intramyocardial tunnel that was visualized by contrast injection into the enlarged coronary artery (middle panel) and balloon occlusion of the exit point of the tunnel. The tunnel was opened, both entry and exit points were closed, and the tunnel was obliterated. (C) Transcoronary closure was performed in a child with aneurysmatic right coronary artery (RCA) draining into the RA. Contrast injection into the RCA (middle panel) delineated the aneurysm. The aneurysm was opened, normal coronary orifices were inspected, both entry and exit points were closed, and the aneurysm was partially resected and obliterated.
The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur )
Copyright © 2015 The Society of Thoracic Surgeons Terms and Conditions