Giant Aneurysm in a Coronary-Pulmonary Artery Fistula

To the Editor,

A 67-year-old woman, with no cardiovascular risk factors and asymptomatic from the cardiologic point of view, was referred to our unit for the study of a cystic mass adjacent to the cardiac outline, detected incidentally on a chest radiograph (Figure 1). The transthoracic echocardiogram showed a large spherical mass with a hyperechogenic wall and heteroechoic content, situated at the level of the atrio-ventricular sulcus, adjacent to the aortic root (Figure 1, Video 1). Multislice computerized tomography and coronary angiography showed a fistula between the right coronary artery and the pulmonary artery, which originated near the ostium of the right coronary artery and drained into the main pulmonary artery via a giant aneurysm, with parietal calcification and mural thrombus (Figure 2, Video 2). Once the presence of a major left-to-right shunt and myocardial ischemia had been ruled out, a wait-and-see attitude was adopted.

Figure 1. The left side of the image is the chest radiograph of the patient, showing a paracardiac cystic mass. The transthoracic echocardiogram shows a heteroechoic mass adjacent to the aortic root.

Figure 2. Multidetector computed tomography and invasive coronary angiogram: fistula of the right coronary artery to the pulmonary artery with a giant thrombosed aneurysm.

Coronary fistulas are anomalous communications, either congenital or acquired, between a coronary artery and a cardiac chamber or blood vessel, present in 0.1%¿0.8% of all coronary angiographies.¹ The development of saccular aneurysms in coronary¿pulmonary fistulas is even less common.² Most arise from the right coronary artery or the left anterior descending artery, and about 90% drain into the venous circulation (right chambers, pulmonary artery, superior vena cava or coronary sinus).¹ Its spectrum of clinical presentation varies, and depends on the severity of the left-to-right shunt. The entity is usually an incidental finding, though it may cause myocardial ischemia, arrhythmias, heart failure or sudden death.¹ As shown by our case, multislice computerized tomography permits clear definition of the origin of these fistulas, their path and their distal site of drainage, as well as their relationship to other cardiac structures, and represents a very important advance in diagnostics, compared with coronary angiography. The main indications for closure of these fistulas are the development of clinical symptoms, especially myocardial ischemia or heart failure. In childhood, treatment can be considered in asymptomatic patients with a high-flow left-to-right shunting to avoid complications. Both surgical treatment and percutaneous closure have shown excellent results with respect to effectiveness, morbidity and mortality.¹

Appendix. Supplementary material

Supplementary material associated with this article can be found in the online version available at doi:10.1016/j.rec.2010.08.002.

Appendix. Supplementary material

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