PMC10130432_01
(A) Chest x-ray showed gross cardiomegaly. (B-E) Transthoracic echocardiography. (B) The parasternal short-axis image showed a large fistula, originating in LMCA. (C) Modified four-chamber view showed the fistula drained from LMCA into RA, adjacent to the coronary sinus. (D) A continuous systolic-diastolic flow inside the structure at color Doppler, which was confirmed at continuous wave Doppler directed from the LMCA toward RA. (E) Cardiac vegetations were found on the orifice of the fistula in the RA. Computed tomography angiography (F,G) and coronary angiography (H). A large fistula originating from LMCA and entering into RA was shown, and the LAD and OM arteries originate directly from LMCA (G,H). (I) Intraoperative findings. An abnormal vascular channel between left aortic sinus and RA (probe) was observed. AO, aorta; CS, coronary sinus; LA, left atrium; LAD, left anterior descending coronary artery; LMCA, left main coronary artery; LCX, left circumflex coronary artery; LV, left ventricle; OMA, oblique marginal artery; PA, pulmonary artery; RA, right atrium; RCA, right coronary artery; RV, right ventricle.
fcvm-10-1101750-g001.jpg
PMC10130432_01_fcvm-10-1101750-g001.jpg
F1
Chest x-ray showed gross cardiomegaly (Figure 1A). Transthoracic echocardiography (TTE) showed that a giant fistula structure between the left coronary sinus (CS) and the RA, and the LMCA diameter was 19 mm (Figure 1B). The opening of the fistula in the RA was adjacent to the CS (Figure 1C), with a diameter of 6 mm. Blood initially passes from the high-pressure aorta to the RA, thereby leading to left-to-right shunt (Figure 1D). In addition, cardiac vegetations were found on the orifice of the fistula in the RA (Figure 1E). LMCA. LMCA originated from the left CS and coursed along the coronary sulcus to form the dilated left circumflex artery (LCX) (Figure 1F). The volume-rendered image demonstrates the fistulous communication to the LMCA and the RA (Figure 1G). CS. Coronary angiography showed a very large CAF originating from the left CS and terminating directly into the RA (Figure 1H). The CAF was identified (Figure 1I), with complete resection vegetations on the orifice of the fistula in the RA.