PMC9966173_01
Computer tomography angiography of the coronary arteries with contrast material. (
A
) Multiplanar reconstructions show the orifice of the fistula into the coronary sinus (arrowhead). (
B
) A dilated tortuous right coronary artery (RCA: thick arrow). (
C
) The right posterolateral branch (PL) of the RCA enters the massively aneurysmatic coronary venous sinus (orifice: arrowhead; sinus: thin arrow) near the inferior atrial septum as a coronary fistula with an orifice of 3 x 8 mm. (
D
) Three-dimensional volume rendering image shows the aneurysmatic coronary venous sinus (thin arrow) from a left anterior oblique view and the course of the RCA (thick arrow) with its PL branch draining into the coronary sinus from a posterior view. The left ventricle (star) is compressed by the aneurysmatic coronary sinus.
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Further investigation with contrast-enhanced computed tomography (CT) visualized an ectatic right coronary artery (RCA) measuring 10 x 10 mm over the entire course through the right atrioventricular groove, a coronary fistula (CF) of the right posterolateral artery after a tortuous course into the coronary sinus (CS) near the inferior atrial septum, as well as a severe dilatation of the CS to 9.5 x 4.5 cm over a length of approximately 13 cm ( Fig. 1 ).
Intraoperative images. (
A
) Coronary sinus aneurysm (CSA). (
B
) Closing the right coronary artery (RCA) fistula into the CS with a direct suture (arrow). (
C
) Reconstruction of the CS using a bovine pericardial patch (arrow). (
D
) Dilated tortuous RCA. RV, right ventricle. (RV = right ventricle, CSA = Coronary sinus Aneurysm).
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After CPB initiation and exposure to the giant CS ( Fig. 2A ), the RCA was circumferentially dissected and encircled with Silastic tapes and a tourniquet. The fistula was closed with direct sutures ( Fig. 2B ). A reconstruction of the CS with a bovine pericardial patch in a tunnel-shaped was performed ( Fig. 2C ), and the aneurysm sac was closed.