Surgical closure of the Right Coronary Artery - Right Atrium Fistula and Repair of Tricuspid Regurgitation Following a Failed Transcatheter Closure

Surgical closure of the Right Coronary Artery - Right Atrium Fistula and Repair of Tricuspid Regurgitation Following a Failed Transcatheter Closure | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Surgical closure of the Right Coronary Artery - Right Atrium Fistula and Repair of Tricuspid Regurgitation Following a Failed Transcatheter Closure Kosgei Godwin Kiplimo, Mei Li, Hongwei Zhang, Hongbiao Tang, Hongjia Ma, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7090729/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 17 You are reading this latest preprint version Abstract Coronary arteriovenous fistulae (CAF), a rare coronary anomaly with a prevalence of approximately 0.002% in the general population, may be congenital or acquired and are often diagnosed incidentally through cardiac imaging. We describe a surgical closure of the fistula and tricuspid valve repair, following the failed minimally invasive intervention that resulted in rupture of the posterior leaflet chordae of the tricuspid valve. Closure of the fistula with a pericardial patch, along with tricuspid valve repair using a Cosgrove-Edwards annuloplasty ring was successfully performed. This case highlights the importance of timely surgical intervention in managing complications of failed percutaneous procedures for coronary arteriovenous fistulae, emphasizing the value of individualized, multidisciplinary approaches in complex cardiovascular anomalies. Figures Figure 1 Figure 2 Introduction Coronary artery fistulas (CAF) are rare congenital or acquired anomalies characterized by abnormal communication between a coronary artery and a cardiac chamber or great vessel [ 1 ] . They are often detected incidentally and typically involve the right heart, either as isolated anomalies or in association with congenital heart disease [ 1 ] . Angiography remains the gold standard for diagnosis [ 2 ] . Management strategies include conservative treatment, surgical repair, or transcatheter occlusion, depending on the fistula’s morphology and local expertise [ 2 ] . We report a surgical correction of CAF after an unsuccessful interventional closure that resulted in ruptured tricuspid valve chordae and acute regurgitation. Case Presentation A 46-year-old female with mild chest discomfort, otherwise healthy and hemodynamically stable, was undergoing preoperative evaluation for vocal cord surgery. A routine transthoracic echocardiography (TTE) revealed a dilated right coronary artery (RCA).Volume rendered computed tomography angiography (CTA) confirmed a dilated 11 mm RCA. The fistula, 9 mm in diameter, bifurcated from the main RCA and drained into the right atrium near the superior vena cava (Fig. 1 A). The patient was scheduled for transcatheter closure. However, during catheter advancement through the femoral vein, the posterior tricuspid valve chordae were ruptured, resulting in acute severe tricuspid regurgitation. The intervention was aborted, and emergent surgical correction of coronary fistula and tricuspid valve repair was planned after thorough review with the patient and her family. A median sternotomy was performed, revealing a quiver-like motion over the right atrium due to large left-to-right shunting (Fig. 2 A; Suplimentary video). Cardiopulmonary bypass was established, followed by cardiac arrest. The right coronary trunk was incised at the bifurcation, and a 1.5 cm² bovine pericardial patch was used to occlude the fistula origin with interrupted 6 − 0 Prolene sutures (Fig. 2 B). Patency of the distal RCA was confirmed with a 1.5 mm probe before the right coronary trunk was closed with running 6 − 0 Prolene sutures (Fig. 2 C). The fistula termination at the right atrium was also closed using 4 − 0 Prolene running sutures (Fig. 2 D). On inspection, the posterior leaflet of the tricuspid valve was prolapsed due to ruptured chordae. Reconstruction was performed with 6 − 0 Prolene to reattach the posterior leaflet to the septal leaflet. A 28 mm Cosgrove-Edwards annuloplasty ring was applied to reinforce the annulus. After successful weaning from CPB, intraoperative transesophageal echocardiography (TEE) showed no abnormal flow into the right atrium and only trace tricuspid regurgitation with 1 mmHg of mean transvalvular gradient. Volume rendered CTA confirmed successful closure of the fistula with no effect on the patency of the distal RCA(Fig. 1 B). Total CPB and aortic clamp times were 125 and 104 minutes respectively. The postoperative course was uneventful. The patient remained in the intensive care unit for two days and was discharged on postoperative day four Discussion CAF can be classified as small, medium, or large when the fistula diameter is 2x the diameter of the largest non-fistulized coronary vessel [ 3 ] . Simple or complex classification is based on vessel origin, pathway, and termination. Studies report LAD- and RCA-derived fistulas in 25–42% and 50–60% of cases, respectively, most commonly draining into the right atrium or right ventricle [ 8 ] . Our patient presented with a large, complex RCA–RA fistula. The coronary “steal phenomenon” is considered the main pathophysiological mechanism in high-flow CAF without outflow obstruction [ 4 ] . Although spontaneous closure is occasionally observed, the risk of complications supports closure either surgically or via percutaneous techniques [ 5 ] . The decision depends on fistula morphology, operator experience, and patient-specific factors [ 6 ] . Our patient had a large fistula that resulted in a visible quiver-like motion on the right atrium. Transcatheter closure (TCC) is favored when anatomical criteria are met [ 7 ] . However, as with any coronary procedure, risks include vessel trauma, rupture, dissection, and arrhythmias [ 9 ] . Reidy et al. recommended TCC as the first-line approach, though complications like device malfunction (e.g., early balloon deflation) have been reported without severe outcomes [ 8 ] . Other procedural complications include ST-T changes, atrial arrhythmias, device migration, and coronary dissection, but these are generally transient and not life-threatening [ 9 ] . In our case, catheter manipulation resulted in rupture of the posterior tricuspid valve chordae, leading to acute valve regurgitation which is a rare complication, requiring early surgical intervention. Surgical correction of CAF was first described by Biorck in 1947 and remains the most definitive treatment, especially for complex or failed TCC cases [ 8 ] . We opted for a bovine pericardial patch, which has shown superior adaptability and durability in closing large, tortuous fistulas [ 10 , 11 ] . Direct suturing may risk vessel distortion or inadequate closure, whereas bovine pericardium conforms better and preserves vessel anatomy [ 12 ] . Conclusion Even in asymptomatic or incidentally discovered cases, large coronary arteriovenous fistulas with high-flow, left-to-right shunt and complex morphology may require surgical correction especially when TCC fails or causes severe complications. In our case, surgical repair involving closure of both fistula ends and tricuspid valve reconstruction achieved hemodynamic stability and preserved coronary function. Surgical treatment is generally reserved for large,complex fistulae that are present with complications characterized by high-fistula flow and very tortuous pathways. Declarations Conflict of interest: The authors declare no competing interests. Funding: This work was supported by the Department of Science and Technology in Sichuan province (23ZDYF2334). Ethics approval and consent to participate: Written informed consent was obtained from the individual for the publication of any potentially identifiable images or data included in this article. Disclosures: Not applicable. Author Contribution Data Sharing Statement: The data generated during this study are available from the corresponding author upon reasonable request.Author contributions: Kosgei Godwin Kiplimo, Chaoyi Qin contributed to the conception and design of the study. Mei Li and Hongwei Zhang were responsible for image processing. Chaoyi Qin and Wei Meng contributed to the execution of the surgery. Wei Meng also participated in manuscript review and the final approval of the submitted version. All authors have read and approved the final manuscript.Acknowledgement: Not applicable.Ethics approval and consent to participate: Written informed consent was obtained from the individual for the publication of any potentially identifiable images or data included in this article.Disclosures: Not applicable. References Sommer, R.J., Z.M. Hijazi, and J.F. Rhodes, Pathophysiology of congenital heart disease in the adult: part III: Complex congenital heart disease. Circulation, 2008. 117(10): p. 1340–50. Warnes, C.A., et al., ACC/AHA 2008 Guidelines for the Management of Adults with Congenital Heart Disease: Executive Summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing committee to develop guidelines for the management of adults with congenital heart disease). Circulation, 2008. 118(23): p. 2395–451. Chen, Z., et al., Precise measurement of coronary stenosis diameter with CCTA using CT number calibration. Med Phys, 2019. 46(12): p. 5514–5527. Dimitrakakis, G., et al., Surgical repair of triple coronary-pulmonary artery fistulae with associated atrial septal defect and aortic valve regurgitation. Interact Cardiovasc Thorac Surg, 2008. 7(5): p. 933–4. Ismail, A.Q., et al., A neonatal case of congenital coronary artery fistula. BMJ Case Rep, 2012. 2012. Saighi Bouaouina, M., et al., Transcatheter Occlusion of Coronary-Pulmonary Fistula With a Liquid Embolic Agent After Evaluation by FFR. JACC Case Rep, 2022. 4(7): p. 391–394. Lee, C.M., et al., Identification of a coronary-to-bronchial-artery communication with MDCT shows the diagnostic potential of this new technology: case report and review. J Thorac Imaging, 2007. 22(3): p. 274–6. Challoumas, D., et al., Coronary arteriovenous fistulae: a review. Int J Angiol, 2014. 23(1): p. 1–10. Wei, P., et al., Comparison of Embolization Coils and Patent Ductus Arteriosus Occluders for Coronary Artery Fistula Transcatheter Closure: A Single Centre Experience. Korean Circ J, 2025. 55(3): p. 199–212. Song, Y., et al., Surgical Management of Coronary Artery Fistulas in Children. J Chest Surg, 2024. 57(1): p. 79–86. Li, X., et al., Current usage and future directions for the bovine pericardial patch. Ann Vasc Surg, 2011. 25(4): p. 561–8. Armsby, L.R., et al., Management of coronary artery fistulae. Patient selection and results of transcatheter closure. J Am Coll Cardiol, 2002. 39(6): p. 1026–32. Additional Declarations No competing interests reported. Supplementary Files Supplementaryvideo.mp4 Suplimentary Video Legends. Hemodynamic Effect of Left-to-Right Shunt: Quiver Motion of Right Atrium. A quiver-like motion over the right atrium (dashed circle) due to high-flow, left-to-right shunt. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 19 Nov, 2025 Reviews received at journal 27 Aug, 2025 Reviews received at journal 25 Aug, 2025 Reviews received at journal 23 Aug, 2025 Reviews received at journal 23 Aug, 2025 Reviews received at journal 17 Aug, 2025 Reviews received at journal 17 Aug, 2025 Reviewers agreed at journal 17 Aug, 2025 Reviewers agreed at journal 16 Aug, 2025 Reviewers agreed at journal 15 Aug, 2025 Reviewers agreed at journal 14 Aug, 2025 Reviewers agreed at journal 14 Aug, 2025 Reviewers agreed at journal 14 Aug, 2025 Reviewers invited by journal 14 Aug, 2025 Editor assigned by journal 14 Jul, 2025 Submission checks completed at journal 14 Jul, 2025 First submitted to journal 10 Jul, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7090729","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":502754658,"identity":"0e7b2e6c-7880-47b5-91fb-c164517e90fe","order_by":0,"name":"Kosgei Godwin Kiplimo","email":"","orcid":"","institution":"West China Hospital of Sichuan University","correspondingAuthor":false,"prefix":"","firstName":"Kosgei","middleName":"Godwin","lastName":"Kiplimo","suffix":""},{"id":502754660,"identity":"595533e2-0061-4b0c-8c4f-8739d01e7dd9","order_by":1,"name":"Mei Li","email":"","orcid":"","institution":"West China Hospital of Sichuan University","correspondingAuthor":false,"prefix":"","firstName":"Mei","middleName":"","lastName":"Li","suffix":""},{"id":502754662,"identity":"dc759c24-37ef-49fd-9c23-95a9e7a20a10","order_by":2,"name":"Hongwei Zhang","email":"","orcid":"","institution":"West China Hospital of Sichuan University","correspondingAuthor":false,"prefix":"","firstName":"Hongwei","middleName":"","lastName":"Zhang","suffix":""},{"id":502754664,"identity":"3b490a17-d881-409f-95eb-7c09cbf89f50","order_by":3,"name":"Hongbiao Tang","email":"","orcid":"","institution":"The First Hospital of Liangshang, Xichang, China","correspondingAuthor":false,"prefix":"","firstName":"Hongbiao","middleName":"","lastName":"Tang","suffix":""},{"id":502754665,"identity":"b4484833-82e4-403e-83e7-43d0e8465aaf","order_by":4,"name":"Hongjia Ma","email":"","orcid":"","institution":"West China Hospital of Sichuan University","correspondingAuthor":false,"prefix":"","firstName":"Hongjia","middleName":"","lastName":"Ma","suffix":""},{"id":502754666,"identity":"a324aae2-2598-4b73-af9c-61d98f78aae7","order_by":5,"name":"Chaoyi Qin","email":"","orcid":"","institution":"West China Hospital of Sichuan University","correspondingAuthor":false,"prefix":"","firstName":"Chaoyi","middleName":"","lastName":"Qin","suffix":""},{"id":502754667,"identity":"5c7dde39-42ac-45c2-a523-31ec4463401a","order_by":6,"name":"Wei Meng","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAvklEQVRIiWNgGAWjYPACCTkGBh4StRiTrIUhsYFoLbrtvYdf81RYpG84fvbwh59tDPLmhLSYnTmXZs1zRiJ3w5m8NMneNgbDnQ2EtNzIMTPObZPI3XaDx4yZsY0hweAAIS333wC1/JNIN7vBY/yZOC1AlY9zGyQSgAwDaeK0nMkxY/5zTMJwP5Ah2XNOwnADQS3Hzxh/nFFTJy/Zfsb4w48yG3mCtgABmwQSRwKnMmTA/IEoZaNgFIyCUTByAQBHnj50RLU/hQAAAABJRU5ErkJggg==","orcid":"","institution":"West China Hospital of Sichuan University","correspondingAuthor":true,"prefix":"","firstName":"Wei","middleName":"","lastName":"Meng","suffix":""}],"badges":[],"createdAt":"2025-07-10 08:38:15","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7090729/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7090729/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":89657087,"identity":"f3fc1e61-b565-4fed-af8f-c3bcca688cf3","added_by":"auto","created_at":"2025-08-22 10:32:16","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":62075,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePre- and post-operative imaging findings.\u003cbr\u003e\n \u003c/strong\u003e(A) \u0026nbsp;Volume rendered CTA showing the distal RCA and the fistula originating from the proximal RCA, arching over the right heart and draining into the right atrium. AAo: ascending aorta; LAD: left anterior descending artery.\u003c/p\u003e\n\u003cp\u003e(B) Post-operative volume rendered CTA \u0026nbsp;showing absence of abnormal flow into the right atrium following successful surgical closure of the fistula.\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7090729/v1/957b2b788bc06764e33f9abb.jpg"},{"id":89657091,"identity":"706539e9-5b73-419b-8d3e-ad2b174165a6","added_by":"auto","created_at":"2025-08-22 10:32:16","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":91644,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eIntraoperative images illustrating surgical management of a right coronary artery–right atrial (RCA–RA) fistula.\u003c/strong\u003e\u003cbr\u003e\n \u003cstrong\u003e(A)\u003c/strong\u003e Initial exposure showing the dilated right coronary artery (RCA) before and after it bifurcated coursing over the right atrium (RA),indicated by the curved dashed line. Right atrium (LA)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(B)\u003c/strong\u003e \u0026nbsp;Closure of the fistula origin using a bovine pericardial patch secured with interrupted 6-0 Prolene sutures, demonstrating the adaptability of the patch within the RCA lumen.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(C)\u003c/strong\u003e A 1.5 mm probe confirming distal coronary perfusion after occlusion at the opening of the fistula.\u003cbr\u003e\n \u003cstrong\u003e(D)\u003c/strong\u003e The distal termination of the fistula (blue arrow) in the right atrial wall.\u003c/p\u003e","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7090729/v1/a7eda4eb9f22ce9500259ba1.jpg"},{"id":89658834,"identity":"f74f1f2e-6a46-444b-b4f0-037d2d280641","added_by":"auto","created_at":"2025-08-22 10:48:20","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":518573,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7090729/v1/1798751e-7669-48be-8da9-166f839e09cf.pdf"},{"id":89657100,"identity":"e9a86384-5065-4fc0-b55e-f6847cc8d002","added_by":"auto","created_at":"2025-08-22 10:32:16","extension":"mp4","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":694804,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSuplimentary Video Legends.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHemodynamic Effect of Left-to-Right Shunt: Quiver Motion of Right Atrium.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA quiver-like motion over the right atrium (dashed circle) due to high-flow, left-to-right shunt.\u003c/p\u003e","description":"","filename":"Supplementaryvideo.mp4","url":"https://assets-eu.researchsquare.com/files/rs-7090729/v1/e78551774c6a2d7e45ada63f.mp4"}],"financialInterests":"No competing interests reported.","formattedTitle":"Surgical closure of the Right Coronary Artery - Right Atrium Fistula and Repair of Tricuspid Regurgitation Following a Failed Transcatheter Closure","fulltext":[{"header":"Introduction","content":"\u003cp\u003eCoronary artery fistulas (CAF) are rare congenital or acquired anomalies characterized by abnormal communication between a coronary artery and a cardiac chamber or great vessel\u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e. They are often detected incidentally and typically involve the right heart, either as isolated anomalies or in association with congenital heart disease\u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e. Angiography remains the gold standard for diagnosis\u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e. Management strategies include conservative treatment, surgical repair, or transcatheter occlusion, depending on the fistula’s morphology and local expertise\u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e. We report a surgical correction of CAF after an unsuccessful interventional closure that resulted in ruptured tricuspid valve chordae and acute regurgitation.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eA 46-year-old female with mild chest discomfort, otherwise healthy and hemodynamically stable, was undergoing preoperative evaluation for vocal cord surgery. A routine transthoracic echocardiography (TTE) revealed a dilated right coronary artery (RCA).Volume rendered computed tomography angiography (CTA) confirmed a dilated 11 mm RCA. The fistula, 9 mm in diameter, bifurcated from the main RCA and drained into the right atrium near the superior vena cava (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eA).\u003c/p\u003e\u003cp\u003eThe patient was scheduled for transcatheter closure. However, during catheter advancement through the femoral vein, the posterior tricuspid valve chordae were ruptured, resulting in acute severe tricuspid regurgitation. The intervention was aborted, and emergent surgical correction of coronary fistula and tricuspid valve repair was planned after thorough review with the patient and her family.\u003c/p\u003e\u003cp\u003eA median sternotomy was performed, revealing a quiver-like motion over the right atrium due to large left-to-right shunting (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eA; Suplimentary video). Cardiopulmonary bypass was established, followed by cardiac arrest. The right coronary trunk was incised at the bifurcation, and a 1.5 cm² bovine pericardial patch was used to occlude the fistula origin with interrupted 6 − 0 Prolene sutures (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eB). Patency of the distal RCA was confirmed with a 1.5 mm probe before the right coronary trunk was closed with running 6 − 0 Prolene sutures (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eC). The fistula termination at the right atrium was also closed using 4 − 0 Prolene running sutures (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eD).\u003c/p\u003e\u003cp\u003eOn inspection, the posterior leaflet of the tricuspid valve was prolapsed due to ruptured chordae. Reconstruction was performed with 6 − 0 Prolene to reattach the posterior leaflet to the septal leaflet. A 28 mm Cosgrove-Edwards annuloplasty ring was applied to reinforce the annulus. After successful weaning from CPB, intraoperative transesophageal echocardiography (TEE) showed no abnormal flow into the right atrium and only trace tricuspid regurgitation with 1 mmHg of mean transvalvular gradient. Volume rendered CTA confirmed successful closure of the fistula with no effect on the patency of the distal RCA(Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eB). Total CPB and aortic clamp times were 125 and 104 minutes respectively.\u003c/p\u003e\u003cp\u003eThe postoperative course was uneventful. The patient remained in the intensive care unit for two days and was discharged on postoperative day four\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eCAF can be classified as small, medium, or large when the fistula diameter is \u0026lt;\u0026thinsp;1x, 1\u0026ndash;2x, or \u0026gt;\u0026thinsp;2x the diameter of the largest non-fistulized coronary vessel\u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e. Simple or complex classification is based on vessel origin, pathway, and termination. Studies report LAD- and RCA-derived fistulas in 25\u0026ndash;42% and 50\u0026ndash;60% of cases, respectively, most commonly draining into the right atrium or right ventricle\u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e. Our patient presented with a large, complex RCA\u0026ndash;RA fistula.\u003c/p\u003e\u003cp\u003eThe coronary \u0026ldquo;steal phenomenon\u0026rdquo; is considered the main pathophysiological mechanism in high-flow CAF without outflow obstruction\u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e. Although spontaneous closure is occasionally observed, the risk of complications supports closure either surgically or via percutaneous techniques\u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e. The decision depends on fistula morphology, operator experience, and patient-specific factors\u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e. Our patient had a large fistula that resulted in a visible quiver-like motion on the right atrium.\u003c/p\u003e\u003cp\u003eTranscatheter closure (TCC) is favored when anatomical criteria are met\u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e. However, as with any coronary procedure, risks include vessel trauma, rupture, dissection, and arrhythmias\u003csup\u003e[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e. Reidy et al. recommended TCC as the first-line approach, though complications like device malfunction (e.g., early balloon deflation) have been reported without severe outcomes\u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e. Other procedural complications include ST-T changes, atrial arrhythmias, device migration, and coronary dissection, but these are generally transient and not life-threatening\u003csup\u003e[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eIn our case, catheter manipulation resulted in rupture of the posterior tricuspid valve chordae, leading to acute valve regurgitation which is a rare complication, requiring early surgical intervention.\u003c/p\u003e\u003cp\u003eSurgical correction of CAF was first described by Biorck in 1947 and remains the most definitive treatment, especially for complex or failed TCC cases\u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e. We opted for a bovine pericardial patch, which has shown superior adaptability and durability in closing large, tortuous fistulas\u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e. Direct suturing may risk vessel distortion or inadequate closure, whereas bovine pericardium conforms better and preserves vessel anatomy\u003csup\u003e[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eEven in asymptomatic or incidentally discovered cases, large coronary arteriovenous fistulas with high-flow, left-to-right shunt and complex morphology may require surgical correction especially when TCC fails or causes severe complications. In our case, surgical repair involving closure of both fistula ends and tricuspid valve reconstruction achieved hemodynamic stability and preserved coronary function. Surgical treatment is generally reserved for large,complex fistulae that are present with complications characterized by high-fistula flow and very tortuous pathways.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eConflict of interest: The authors declare no competing interests.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFunding:\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eThis work was supported by\u0026nbsp;the Department of Science and Technology in\u0026nbsp;Sichuan province\u0026nbsp;(23ZDYF2334).\u003c/p\u003e\n\u003cp\u003eEthics approval and consent to participate: Written informed consent was obtained from the individual for the publication of any potentially identifiable images or data included in this article.\u003c/p\u003e\n\u003cp\u003eDisclosures: Not applicable.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eData Sharing Statement: The data generated during this study are available from the corresponding author upon reasonable request.Author contributions: Kosgei Godwin Kiplimo, Chaoyi Qin contributed to the conception and design of the study. Mei Li and Hongwei Zhang were responsible for image processing. Chaoyi Qin and Wei Meng contributed to the execution of the surgery. Wei Meng also participated in manuscript review and the final approval of the submitted version. All authors have read and approved the final manuscript.Acknowledgement: Not applicable.Ethics approval and consent to participate: Written informed consent was obtained from the individual for the publication of any potentially identifiable images or data included in this article.Disclosures: Not applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSommer, R.J., Z.M. Hijazi, and J.F. Rhodes, Pathophysiology of congenital heart disease in the adult: part III: Complex congenital heart disease. Circulation, 2008. 117(10): p. 1340\u0026ndash;50.\u003c/li\u003e\n\u003cli\u003eWarnes, C.A., et al., ACC/AHA 2008 Guidelines for the Management of Adults with Congenital Heart Disease: Executive Summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing committee to develop guidelines for the management of adults with congenital heart disease). Circulation, 2008. 118(23): p. 2395\u0026ndash;451.\u003c/li\u003e\n\u003cli\u003eChen, Z., et al., Precise measurement of coronary stenosis diameter with CCTA using CT number calibration. Med Phys, 2019. 46(12): p. 5514\u0026ndash;5527.\u003c/li\u003e\n\u003cli\u003eDimitrakakis, G., et al., Surgical repair of triple coronary-pulmonary artery fistulae with associated atrial septal defect and aortic valve regurgitation. Interact Cardiovasc Thorac Surg, 2008. 7(5): p. 933\u0026ndash;4.\u003c/li\u003e\n\u003cli\u003eIsmail, A.Q., et al., A neonatal case of congenital coronary artery fistula. BMJ Case Rep, 2012. 2012.\u003c/li\u003e\n\u003cli\u003eSaighi Bouaouina, M., et al., Transcatheter Occlusion of Coronary-Pulmonary Fistula With a Liquid Embolic Agent After Evaluation by FFR. JACC Case Rep, 2022. 4(7): p. 391\u0026ndash;394.\u003c/li\u003e\n\u003cli\u003eLee, C.M., et al., Identification of a coronary-to-bronchial-artery communication with MDCT shows the diagnostic potential of this new technology: case report and review. J Thorac Imaging, 2007. 22(3): p. 274\u0026ndash;6.\u003c/li\u003e\n\u003cli\u003eChalloumas, D., et al., Coronary arteriovenous fistulae: a review. Int J Angiol, 2014. 23(1): p. 1\u0026ndash;10.\u003c/li\u003e\n\u003cli\u003eWei, P., et al., Comparison of Embolization Coils and Patent Ductus Arteriosus Occluders for Coronary Artery Fistula Transcatheter Closure: A Single Centre Experience. Korean Circ J, 2025. 55(3): p. 199\u0026ndash;212.\u003c/li\u003e\n\u003cli\u003eSong, Y., et al., Surgical Management of Coronary Artery Fistulas in Children. J Chest Surg, 2024. 57(1): p. 79\u0026ndash;86.\u003c/li\u003e\n\u003cli\u003eLi, X., et al., Current usage and future directions for the bovine pericardial patch. Ann Vasc Surg, 2011. 25(4): p. 561\u0026ndash;8.\u003c/li\u003e\n\u003cli\u003eArmsby, L.R., et al., Management of coronary artery fistulae. Patient selection and results of transcatheter closure. J Am Coll Cardiol, 2002. 39(6): p. 1026\u0026ndash;32.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-cardiothoracic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jcts","sideBox":"Learn more about [Journal of Cardiothoracic Surgery](http://cardiothoracicsurgery.biomedcentral.com)","snPcode":"13019","submissionUrl":"https://submission.nature.com/new-submission/13019/3","title":"Journal of Cardiothoracic Surgery","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-7090729/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7090729/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eCoronary arteriovenous fistulae (CAF), a rare coronary anomaly with a prevalence of approximately 0.002% in the general population, may be congenital or acquired and are often diagnosed incidentally through cardiac imaging. We describe a surgical closure of the fistula and tricuspid valve repair, following the failed minimally invasive intervention that resulted in rupture of the posterior leaflet chordae of the tricuspid valve. Closure of the fistula with a pericardial patch, along with tricuspid valve repair using a Cosgrove-Edwards annuloplasty ring was successfully performed. This case highlights the importance of timely surgical intervention in managing complications of failed percutaneous procedures for coronary arteriovenous fistulae, emphasizing the value of individualized, multidisciplinary approaches in complex cardiovascular anomalies.\u003c/p\u003e","manuscriptTitle":"Surgical closure of the Right Coronary Artery - Right Atrium Fistula and Repair of Tricuspid Regurgitation Following a Failed Transcatheter Closure","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-22 10:32:11","doi":"10.21203/rs.3.rs-7090729/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-11-19T15:50:17+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-27T12:43:39+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-25T04:45:23+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-23T09:28:47+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-23T07:40:36+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-17T20:05:40+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-17T09:23:42+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"59018374475977286150466308301899768025","date":"2025-08-17T05:19:11+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"220871458217217921216784614623971290942","date":"2025-08-16T16:34:39+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"200896494164695538444792030633538430899","date":"2025-08-15T06:21:28+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"196443211213277742422226270577688549445","date":"2025-08-14T21:09:23+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"298075046451752839240894617547310389594","date":"2025-08-14T19:28:25+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"278721909785325674926897655941141576293","date":"2025-08-14T16:34:44+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-14T16:32:01+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-14T11:46:33+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-14T11:46:13+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Cardiothoracic Surgery","date":"2025-07-10T08:24:14+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-cardiothoracic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jcts","sideBox":"Learn more about [Journal of Cardiothoracic Surgery](http://cardiothoracicsurgery.biomedcentral.com)","snPcode":"13019","submissionUrl":"https://submission.nature.com/new-submission/13019/3","title":"Journal of Cardiothoracic Surgery","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"39c37e46-abf7-47e3-b69f-e82149bfe624","owner":[],"postedDate":"August 22nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-01-24T19:53:32+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-22 10:32:11","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7090729","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7090729","identity":"rs-7090729","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}