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Coronary artery aneurysms may develop fistulas which drain into the pulmonary artery and the left ventricle. We present images of a patient with a left main coronary artery aneurysmwhich fistulized into the right atrium (RA). A 38-year-old Asian female presented with a cough and fatigue. A chest X-ray revealed a mass abutting the right heart border (Figure 1). A transesophageal echocardiogram (TEE) demonstrated a large coronary artery aneurysm communicating with the RA (Figure 2). A computed tomography angiogram revealed a left main coronary artery aneurysm, 9.6 × 9.7 × 9.2 cm, extending into the left circumflex artery compressing the right main pulmonary artery, with a 1.5-cm fistulous vessel overlying the dome of the left atrium (Figures 3 and 4). A cardiac catheterization revealed a left main coronary artery aneurysm with a fistulous vessel overlying the right ventricle (RV) (Figure 5). The pulmonary artery pressures were 48/23mmHg and there was evidence of mild left-to-right shunting (QP/QS = 1.3:1). At the time of surgery, a median sternotomy revealed dense pericardial adhesions to the RA and RV. A large left coronary artery aneurysm was found to be encasing the RA free wall and extending toward the superior vena cava. Cardiopulmonary bypass (CPB) was

Left main coronary artery aneurysm with a fistula draining into the right atrium