Abstract
A man aged 73 years who had undergone coronary artery bypass graft presented with orthopnea. Echocardiography showed marked dilatation of the coronary sinus (CS), with a massive intramural thrombus andflow acceleration at its opening, and a high velocity jet from the left ventricle through its posterior wall into an enlarged coronary vein, suggesting dual cardiac fistulas to the CS. Multidetector computed tomography revealed a large aneurysm of the right coronary artery (RCA) with a RCA-CS fistula (red arrows), a left ventricular-CS fistula via posterior coronary vein (blue arrows), and a large CS aneurysm (green arrows) with a massive intramural thrombus (Fig. 1). Cardiac catheterization showed a 3.4:1.0 left-to-right shunt at the level of the right atrium. The highflow RCA-CS fistula was successfully treated by transcatheter coil embolization. The postoperative course was uneventful, and the patient was free of symptoms at a 1-year follow-up. Although there have been several case reports of RCA fistula to
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