PMC7724369_01
EKG on arrival in the ED, showing ischemic changes (T-wave inversion) in the inferior leads (II, III, aVF).
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Initial EKG showed sinus tachycardia and left ventricular hypertrophy with repolarization changes in the anterior chest leads (Fig. 1).
EKG after normalization of blood pressure, showing ischemic changes (T-wave inversion) in the inferior leads.
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Repeat EKG revealed normal sinus rhythm with deep T-wave inversions in the inferior lateral leads (II, III, aVF, I, aVL, V4-V6) suggesting possible coronary ischemia (Fig. 2).
Chest x-ray showing improvement in pulmonary congestion after diuresis.
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Repeat chest x-ray showed a marked improvement in the pulmonary congestion after diuresis (Fig. 3).
CT angiogram of the chest showing the dilated pulmonary artery.
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At that time CT angiogram of the chest revealed 4.8-cm aneurysmal dilatation of the ascending thoracic aorta and extensive bronchiectasis, primarily involving the right middle, upper, and left lower lobes (Fig. 4).
Coronary angiogram of the right coronary system in the right anterior oblique cranial view (left) and the left anterior oblique cranial view (right) showing the normal right coronary artery (blue arrows) and the right coronary-to-pulmonary artery fistula (red arrows). (For interpretation of the references to colour in this figure legend, the reader is referred to the Web version of this article.)
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Repeat coronary angiography performed during this admission also showed right coronary artery patency along with the previously detected fistula (Fig. 5).