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Fistulous connection of left circumflex coronary artery to coronary sinus presenting with massive pericardial effusion/Buyuk perikardiyal efuzyon ile ortaya cikan sol sirkumfleks koroner arterin fistul ile koroner sinuse baglantisi.

Coronary arteriovenous fistula is a rare anomaly through which the involved coronary artery flow drains into a cardiac chamber, great vessel, or other structures, bypassing the myocardial capillary network. The right coronary artery and the right ventricle are the most common origin and distal connection sites, respectively. A left circumflex artery with a fistulous connection to the coronary sinus is extremely rare.

In this report, we presented an extremely rare case of left circumflex coronary artery-coronary sinus fistula associated with restricted sinus opening to right atrium presenting with non-bloody massive pericardial effusion that was probably caused by abnormal pericardial veins drainage.

A 43-year-old-male was referred to our department because of progressive exertional dyspnea during the past 3 months with no risk factor for coronary artery disease. Transthoracic echocardiography showed massive circumferential pericardial effusion, marked dilatation of coronary sinus and multiple echo-free spaces adjacent to left atrioventricular groove (Fig. 1A, B. Video 1, 2. See video/movie images at and (Fig. 1B). Transesophageal imaging with color Doppler flow revealed multiple echo-free spaces with visible flow adjacent to dilated coronary sinus and left circumflex artery. There was aneurysmal dilatation of coronary sinus (5 cm) filled with intramural thrombus and significant narrowing (1-2 mm) with turbulent flow at its opening to the right

atrium (Fig. 2A Video 3, 4. See video/movie images at with high velocity continuous Doppler signal (Fig. 2B). A preoperative cardiac catheterization showed aneurismal dilation and severe tortuosity of left circumflex coronary artery draining into the coronary sinus (Fig. 3). On the basis of these findings, a final diagnosis of coronary artery fistula to the aneurismal coronary sinus was made. The patient underwent surgical treatment under cardiopulmonary bypass. If left untreated, the coronary sinus aneurysm in the present case might have ruptured spontaneously.




Fereshte Ghaderi, Mohammad Abbasi Teshnizi *, Ali Eshraghi Departments of Cardiology and * Cardiovascular Surgery, Faculty of Medicine, Imam Reza Hospital, Mashhad University of Medical Sciences, Mashhad-Iran

Video 1. Transthoracic echocardiography showing dilated left circumflex coronary artery and massive pericardial effusion

Video 2. Color Doppler transthoracic echocardiography showing abnormal continuous flow draining to right atrium

Video 3. Transesophageal echocardiography showing aneurysmal coronary sinus which is partially occluded by the thrombus and restricted sinus opening to right atrium

Video 4. Color Doppler transesophageal echocardiography

Address for Correspondence/Yazisma Adresi: Dr. Fereshte Ghaderi, Department of Cardiology, Community Cardiovascular Health Research Center Imam Reza Hospital, Mashhad University of Medical Sciences, Mashhad-Iran

Phone: +989151615412


Available Online Date/Cevrimici Yayin Tarihi: 29.05.2013

doi: 10.5152/akd.2013.162

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Copyright 2013 Gale, Cengage Learning. All rights reserved.

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Title Annotation:E-page Original Images/E-sayfa Ozgun Goruntuler
Author:Ghaderi, Fereshte; Teshnizi, Mohammad Abbasi; Eshraghi, Ali
Publication:The Anatolian Journal of Cardiology (Anadolu Kardiyoloji Dergisi)
Article Type:Case study
Date:Aug 1, 2013
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