Multiple Coronary Arteriovenous Fistulas to the Coronary Sinus With an Unruptured Coronary Sinus Aneurysm and Restrictive Coronary Sinus Opening to the Right Atrium

A 37-year-old woman was transferred to our departmentfor surgery. She had experienced intermittent chest discomfort or pain and palpitation during the last 4 years. Chest radiographs showed cardiomegaly (cardiothoracic ratio 0.63). A preoperative ECG showed normal sinus rhythm (Figure 1). Echocardiography showed marked dilatation of the coronary sinus with an intramural thrombus and flow acceleration at its opening (Figure 2). Cardiac catheterization showed no significant coronary artery stenosis but revealed coronary arteriovenous fistulas (CAVFs) from the distal right coronary artery, distal left anterior descending artery, and proximal left circumflex artery draining directly into the coronary sinus (Figure 3). A preoperative computed tomog-raphy scan showed a large aneurysm that contained thrombi with a maximal diameter of 73 mm at the outer side of the left ventricular inferior wall (Figure 4). The site of the aneurys