A 49-year-old man presented with progressive exertional dyspnoea associated with palpitations for 4 months’ duration. Physical examination was notable for marked jugular venous distention and a to-and-fro murmur was heard at the apex. A chest x-ray showed significant cardiomegaly with a bulging contour over the right cardiac border (figure 1A). Transthoracic echocardiography revealed the right coronary artery (RCA) was obviously dilated with a huge aneurysm and a fistula draining into the LV, moreover, the right heart chamber was significantly collapsed due to extrinsic compression of the aneurysm (figure 1B). Selective RCA angiography confirmed the presence of two giant saccular aneurysms located in the middle and distal portions of the RCA, associated with an extremely tortuous, diffusely dilated fistula draining into the LV (figure 1C, online supplementary video 1). The cardiac CT angiography images highlighted the multiple and giant size of these aneurysms (figure 1D1,D2). A thallium-201 myocardial single photon emission CT demonstrated normal myocardial perfusion (figure 1E). Surgical treatment was strongly recommended, but the patient refused intervention. Coronary artery fistula (CAF) is defined as an anomalous communication between coronary artery and cardiac chamber or great vessel. Multiple huge coronary artery aneurysm formations accompanied by coronary artery to LV fistula has rarely been reported. Potential complications of the giant aneurysmally dilated CAF include spontaneous rupture, myocardial ischaemia, thrombosis and thromboembolic events.1 Cardiac CT angiography could disclose this disorder precisely and is helpful for planning future therapeutic approach. Myocardial ischaemia detection tests are useful to determine the significance of the giant aneurysmally dilated CAF.2

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Figure 1

(A) A chest roentgenogram showed a significant expansion on the right-heart border. (B) Transthoracic echocardiography revealed a huge right coronary artery aneurysm compressing the right atrium with a fistula draining into the LV. (C) Right coronary angiography confirmed the presence of two giant aneurysms, with an extremely tortuous, diffusely dilated fistula draining into the LV. (D) Three-dimensional reconstruction images highlighted the multiple and giant size of these aneurysms. (E) Single photon emission CT demonstrated normal myocardial perfusion.