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A 75 year old man presented with a two year history of increasing exertional dyspnoea and discomfort in his left arm, both relieved by rest. There was no relevant past medical history, and no history of trauma to the chest. Physical examination revealed a harsh continuous systolic murmur continuing into early diastole at the lower left sternal edge. The murmur did not radiate to the apex, and was felt by the examining clinician to be unusual, and possibly related to a coronary fistula.
Transthoracic echocardiography showed normal left ventricular function with mild mitral regurgitation. No other abnormality was seen. Exercise treadmill test revealed downsloping ST segment depression in association with the patient's usual symptoms at a low work load (3 minutes 50 seconds, Bruce protocol).
At cardiac catheterisation there was no evidence of coronary fistula and no step up in oximetry was demonstrated. Selective coronary angiography revealed an extremely large saccular aneurysm of the right coronary artery (below left) with slow filling of the distal vessel. There was only minimal atherosclerotic disease in the left coronary artery. Magnetic resonance imaging showed a right coronary aneurysm containing slow flowing blood and thrombus, compressing both the right atrium and right ventricle laterally (below right).
A standard saphenous vein coronary artery bypass graft was performed, together with excision of the giant aneurysm. On examination of the patient following surgery, the murmur had resolved, allowing auscultation of a much quieter murmur typical of the documented mitral regurgitation. The symptoms of exertional dyspnoea and arm pain have resolved.