Recommended Citation
Olumuyide E, Toll A. An Unusual Culprit: Right Coronary Artery Aneurysm and Coronary Sinus Fistula Presenting as Acute Heart Failure. Presented at Scientific Day; May 20, 2026; Milwaukee, WI.
Abstract
Background/Significance:
Coronary artery aneurysms associated with coronary fistulae are rare and may cause shunt physiology, ischemia, and heart failure. Multimodality imaging and invasive hemodynamics are essential for diagnosis and management planning.
Description:
A 78-year-old man with hypertension and hyperlipidemia presented with new-onset decompensated heart failure. Transthoracic echocardiography revealed severe biventricular dysfunction (LVEF 10%) with severe aortic and mitral regurgitation. Coronary angiography demonstrated severe multivessel coronary artery disease and a markedly aneurysmal right coronary artery (RCA) with suspected fistulous communication. Right-heart catheterization revealed elevated filling pressures, a reduced cardiac index, and a right atrial oximetry step-up, indicating a left-to-right shunt. Coronary CTA identified a giant RCA aneurysm, while cardiac MRI confirmed an RCA–coronary sinus fistula with Qp/Qs of 1.27. Following medical optimization, the patient underwent bioprosthetic aortic valve replacement, coronary artery bypass grafting, RCA aneurysm exclusion, and fistula ligation with a good clinical outcome
Discussion:
This case illustrates a high-risk, multifactorial substrate for new-onset severe HFrEF involving severe calcific multivessel coronary artery disease, severe multivalvular disease, and a giant RCA aneurysm with an RCA–coronary sinus fistula. Although coronary CTA did not clearly define a discrete fistulous tract, invasive oximetry showed a marked step-up from the superior vena cava to the right atrium, and cardiac MRI confirmed physiologically significant left-to-right shunting (Qp/Qs 1.27), underscoring the value of multimodality imaging integrated with invasive hemodynamics to characterize the heart failure drivers. The markedly dilated RCA (≈10–15 mm) met accepted criteria for a giant coronary artery aneurysm, a lesion associated with thrombosis, embolization, ischemia, rupture, and progressive heart failure risks amplified by concomitant fistula and coronary steal physiology. Given the coexistence of multiple lesions independently capable of worsening heart failure (ischemic burden, severe aortic regurgitation–related LV volume overload, and aneurysm-fistula shunt/steal), a multidisciplinary heart-team approach favored single-stage surgery with CABG ×3, surgical aortic valve replacement, and multi-level RCA ligation to exclude the aneurysm and fistula while preserving distal perfusion via bypass grafting.
Presentation Notes
Presented at Scientific Day; May 20, 2026; Milwaukee, WI.
Full Text of Presentation
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Document Type
Poster
Open Access
Available to all.
An Unusual Culprit: Right Coronary Artery Aneurysm and Coronary Sinus Fistula Presenting as Acute Heart Failure
Background/Significance:
Coronary artery aneurysms associated with coronary fistulae are rare and may cause shunt physiology, ischemia, and heart failure. Multimodality imaging and invasive hemodynamics are essential for diagnosis and management planning.
Description:
A 78-year-old man with hypertension and hyperlipidemia presented with new-onset decompensated heart failure. Transthoracic echocardiography revealed severe biventricular dysfunction (LVEF 10%) with severe aortic and mitral regurgitation. Coronary angiography demonstrated severe multivessel coronary artery disease and a markedly aneurysmal right coronary artery (RCA) with suspected fistulous communication. Right-heart catheterization revealed elevated filling pressures, a reduced cardiac index, and a right atrial oximetry step-up, indicating a left-to-right shunt. Coronary CTA identified a giant RCA aneurysm, while cardiac MRI confirmed an RCA–coronary sinus fistula with Qp/Qs of 1.27. Following medical optimization, the patient underwent bioprosthetic aortic valve replacement, coronary artery bypass grafting, RCA aneurysm exclusion, and fistula ligation with a good clinical outcome
Discussion:
This case illustrates a high-risk, multifactorial substrate for new-onset severe HFrEF involving severe calcific multivessel coronary artery disease, severe multivalvular disease, and a giant RCA aneurysm with an RCA–coronary sinus fistula. Although coronary CTA did not clearly define a discrete fistulous tract, invasive oximetry showed a marked step-up from the superior vena cava to the right atrium, and cardiac MRI confirmed physiologically significant left-to-right shunting (Qp/Qs 1.27), underscoring the value of multimodality imaging integrated with invasive hemodynamics to characterize the heart failure drivers. The markedly dilated RCA (≈10–15 mm) met accepted criteria for a giant coronary artery aneurysm, a lesion associated with thrombosis, embolization, ischemia, rupture, and progressive heart failure risks amplified by concomitant fistula and coronary steal physiology. Given the coexistence of multiple lesions independently capable of worsening heart failure (ischemic burden, severe aortic regurgitation–related LV volume overload, and aneurysm-fistula shunt/steal), a multidisciplinary heart-team approach favored single-stage surgery with CABG ×3, surgical aortic valve replacement, and multi-level RCA ligation to exclude the aneurysm and fistula while preserving distal perfusion via bypass grafting.
Affiliations
Advocate Masonic Medical Center