A three-month-old boy was admitted to our institution due to feeding difficulties for one month. Echocardiography (Figure 1( a ), white arrow) and coronary computed tomographic angiography confirmed the presence of a right coronary artery fistula (Figure 1( b ), white arrow) and a right coronary artery aneurysm (Figure 1( c ), asterisk). The fistula drained into the right ventricle with an open measuring 4 mm in width (Figure 1( a ) and 1( b )). Following a multidisciplinary discussion, surgery was deemed necessary. However, the patient’s parents declined transcatheter closure with a metallic occluder. Given its superior cosmetic outcome, right axillary thoracotomy approach was considered technically feasible and clinically suitable. A 3 cm vertical incision was made to access the thoracic cavity through the fourth intercostal space (Figure 1( d )). Cardiopulmonary bypass was established using standard technique, with both the superior and inferior caval vein snared. Following aortic cross-clamping, del Nido cardioplegia was administered antegrade via the aortic root. Due to runoff of coronary artery fistula, a total volume of 30 mL/kg of cardioplegia was delivered to achieve satisfactory arrest. Attempts to locate the fistulous opening in the right ventricle via right atriotomy were unsuccessful. Consequently, an arteriotomy was performed on the right coronary artery, and a probe was inserted into the fistula (Figure 1( e )), successfully advancing its tip into the right ventricle. The fistula was subsequently closed within the arteriotomy wound using 6-0 Prolene sutures. Cardiopulmonary bypass time and aortic cross-clamp time were 170 and 100 minutes, respectively. The postoperative course was uneventful, and echocardiography before discharge showed no residual shunt (Figure 1( f ), white arrow).

Figure 1.

Repair of a coronary artery fistula via right axillary thoracotomy. (a) Pre-operative echocardiogram shows a right coronary artery fistula (white arrow) (b) 3-D coronary CTA reconstruction shows a right coronary artery fistula (white arrow); (c) 3-D coronary CTA reconstruction shows a right coronary artery aneurysm (asterisk); (d) Right axillary thoracotomy was performed. After pericardial retraction with traction sutures, the aorta and right coronary artery aneurysm are visualised; (e) A probe inserted through the arteriotomy wound and advanced into the right ventricle (asterisk). (f) Post-operative echocardiography before discharge showed no residual shunt (white arrow). 3-D = Three-dimensional; AO = Aorta; RCAA = Right coronary artery aneurysm.

The current treatment for coronary artery fistula include surgical repair and transcatheter closure. Surgery is recommended to prevent congestive heart failure, endocarditis, myocardial infarction, pulmonary hypertension, and embolisation of coronary artery aneurysm. ^{Reference Mangukia1} To the best of our knowledge, this represents the first report of right axillary thoracotomy for the repair of a coronary artery fistula in an infant. With appropriate pericardial suspension, adequate surgical exposure was achieved, providing a technically feasible and cosmetically favourable approach.