Right coronary artery to coronary sinus fistula

A 77-year-old man suffered from dyspnoea due to mitral valve prolapse with chordal rupture. Angiography revealed an aneurysm of the right coronary artery (RCA) due to a fistula to the coronary sinus (CS) (Fig. 1). During mitral valve repair two fistulas from RCA to CS were identified and ligated (Fig. 2). Fig. 1. Preoperative coronary angiogram (A) showing massive dilation of the entire RCA and early filling of the distal parts of the CS with contrast through a large RCA-CS fistula. Preoperative transoesophageal echocardiography (B) demonstrated severe mitral regurgitation due to prolapse of the segment P2 with flail leaflet. In addition two 'jets' (arrows) could be visualized in the CS, demonstrating flow through two distinct RCA-CS fistulas. Postoperative transoesophageal echocardiography after mitral valve repair and ligation of the RCA-CS-fistulas (C) confirmed occlusion of the two fistulas and successful mitral valve repair without detectable mitral regurgitation. LV: left ventricle; LA: left atrium.