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A 66 year old man was referred for further cardiac examination regarding an abnormal finding at x ray (top left) that had gradually enlarged over a 20 year period. At his local hospital a coronary angiogram had revealed a large aneurysm in a coronary pulmonary artery fistula. The fistula originated from the proximal left anterior descending artery, and in the mid portion there was a giant aneurysm measuring 27 mm (long axis) × 20 mm (short axis) filled with contrast material (top right). However, it was difficult to determine from the angiogram the connecting site to the pulmonary artery because of retention of the contrast material in the aneurysm. Echocardiography revealed a thick mural thrombus within the aneurysm (bottom left, arrows) (An, aneurysm; PA, pulmonary artery); the inner dimension was 22 mm × 24 mm, which was compatible with the short axis dimension determined by angiography. However, the outer dimension of the aneurysm as determined by echocardiography was much greater than the dimensions determined by angiography, which explains the huge abnormal shadow in the plain chestx ray. Colour Doppler imaging clearly demonstrated flow from the fistula to the pulmonary artery through the aneurysm (bottom right). The patient underwent resection of the aneurysm with reconstruction of the coronary artery. In this case echocardiography accurately determined the morphology of the aneurysm in terms of its size and site of connection to the pulmonary artery.