Totally endoscopic surgery for closure of a large coronary artery fistula into the right atrium: technic surgical and literature review based on a clinical case

Introduction Coronary artery fistula (CAF) is a rare congenital cardiac anomaly. Although percutaneous closure techniques have more widely developed, surgical closure remains an effective option when intervention fail. The conventional surgical approach via median sternotomy is routinely performed, yet presents many limitations. A totally endoscopic 3D-assisted surgical closure of the fistula is a novel, safe, and effective technique with several advantages. Case Presentation We report a case of an 18-year-old female patient diagnosed with a large left coronary artery-to-right atrium fistula, leading to myocardial ischemia. The fistula was successfully closed using a totally endoscopic 3D-assisted approach via a single 2 cm right-sided submammary incision. Complete closure of the fistula at its drainage site into the right atrium was achieved. Follow-up echocardiography and coronary computed tomography angiography (CCTA) at 8 months postoperatively confirmed no recurrence of the fistula. Discussion Surgical closure of CAF via median sternotomy has several disadvantages, including postoperative pain, bleeding, sternal osteomyelitis, wound infection, and poor cosmetic outcomes. The totally endoscopic 3D-assisted approach provides a three-dimensional view, allowing precise visualization and accurate dissection of the fistula. This technique ensures effective closure of the fistula via a single 2 cm right submammary incision, minimizing blood loss, reducing postoperative pain, and offering excellent cosmetic results, especially for female patients. Conclusion Totally endoscopic 3D-assisted surgery is a safe and effective treatment for selected cases of CAF.