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A 50 year old asymptomatic woman without prior medical history was found to have a continuous murmur, which was loudest in the lower right parasternal region. Her physical examination and standard ECG were normal. Transthoracic echocardiography revealed mild right ventricular dilatation, with trivial tricuspid regurgitation and transvalvar flow velocity estimated at 2.5 m/s. Left ventricular size and systolic function, and all valves, were normal. A hypoechogenic image was identified near the right ascending aortic wall, spherical at its origin, then extending linearly along the right, inferior margin of the right ventricle, without clear termination. Cardiac catheterisation (specially frontal and left lateral views of selective arteriography, performed with a 5 French Amplatz catheter) confirmed the presence of a huge, aneurysmal (measured to 9 mm at its origin), sinuous right coronary artery emptying widely into the right atrium just below the coronary sinus ostium, opacified retrogradely over a few millimetres (black arrow). A small retroventricular arterial branch originated from the anomalous coronary artery (white arrow). Left ventriculography and left coronary angiograms were normal. Right heart and pulmonary artery pressures were normal, though pulmonary output was increased to 7.4 litres/min, with a calculated 1.48:1.0 left-to-right shunt. Exercise stress sestamibi scintigraphy showed normal myocardial perfusion.
This asymptomatic patient was recommended to undergo long term medical surveillance.