Unusual presentation of right coronary artery fistula

Description

A female aged 70 years, with no previous comorbidities, was referred with suspected heart failure due to mild exertional dyspnoea, mildly elevated brain-natriuretic peptide (BNP) (139 ng/L) and inferolateral T-inversion on ECG. A transthoracic echocardiogram (TTE) showed a moderate global pericardial effusion, mild left ventricular hypertrophy (LVH), moderate aortic stenosis (AS) and preserved systolic function. Serial TTE's showed a resolving pericardial effusion, moderate left ventricular hypertrophy (LVH) and bi-atrial dilatation, following which cardiac magnetic resonance imaging (CMR) was requested to exclude infiltrative cardiomyopathy. An angiogram was also requested due to suspicion of moderate-to-severe AS, as a work-up for future valve replacement. CMR showed a severely dilated and tortuous right coronary artery (RCA) on Half-Fourier-Acquired Single-shot Turbo spin Echo (HASTE) planning images, draining into an enlarged coronary sinus (figure 1A,B). There was moderate lateral wall hypertrophy on cine images (figure 1C,D), with corresponding oedema (increased native T1 value on T1...

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