CT-based 3D printing of giant coronary artery fistulas to guide surgical strategy: a case series

Abstract Background Coronary artery fistulas (CAF´s) are abnormal communications between the coronary arteries and the heart chambers, arteries or veins, potentially leading to significant shunting, myocardial ischemia and heart failure. Computed tomographic (CT) angiography or conventional invasive angiography is the reference standard for the diagnosis of coronary fistulas. The fistula anatomy can become very complex, which makes the surgical or interventional planning challenging. Case summary We report two cases of hugely dilated and tortuous coronary circumflex artery fistulas draining into the coronary sinus. Both patients were followed for more than 10 years because of very complex coronary fistula anatomy and mild symptoms. From 2-dimentional sliced CT images alone it was uncertain whether surgery was feasible. However, since both patients had symptom progression (patient 1 developed heart failure and patient 2 had recurrent pericardial effusions) 3D heart models were printed for better understanding of the complex fistula anatomy and improved surgical planning. Both patients had a successful surgery and symptomatic relieve at follow-up. Discussion The delay in surgery, until clinical deterioration, may partly be a consequence of a general reluctance in performing complex surgery in patients with CAF’s. As of now, CT-based 3D-printing has primarily been used in isolated cases. However, 3D-printing is evolving rapidly and supplementing 2D sliced CT images with a physical 3D heart model may improve the anatomical understanding and pre-surgical-planning which could lead to better surgical outcome.