case_images: PMC9644096_01
case_images: Three-dimensional zoom mid esophageal echocardiography (A) shows dilated left circumflex artery (LCX; light blue arrow) and coronary sinus (CS), (B) tortuous, giant coronary fistula (white arrow), (C,D) mid esophageal full volume illustrating the same findings.
case_images: fcvm-09-986078-g001.jpg
case_images: PMC9644096_01_fcvm-09-986078-g001.jpg
case_images: F1
case_images: Two years after her operation, the results of routine follow-up echocardiography and 2D TEE raised the possibility of a connection between the left circumflex artery and coronary sinus (Supplementary Figure 1), confirmed by more investigations such as conventional coronary angiography and CCTA. In the recent referral of the patient, 3D TEE was performed, which clearly identified CAF courses and low-velocity flow throughout the whole cardiac cycle, which drained into the coronary sinus (venous system) (Figure 1).
case_images: Coronary artery cineangiography in 30  RAO (left; A) and 60  LAO (right; B) projections show a giant coronary artery (red isosceles triangles) starting from the proximal left circumflex artery and terminating in the same artery (narrow arrows).
case_images: fcvm-09-986078-g002.jpg
case_images: PMC9644096_02_fcvm-09-986078-g002.jpg
case_images: F2
case_images: TEE (2D and 3D) showed CAF courses and low-velocity flow throughout the whole cardiac cycle, which drained into the superior vena cava (Supplementary Figure 2).
case_images: Contrast-enhanced CT scan of the chest, as well as CCTA, show the proximal site of a giant fistula originating from the left circumflex artery (white arrow), draining into the coronary sinus and forming a pouch (blue arrow). Reconstruction of coronaries illustrates a giant fistula (red color arrowheads).
case_images: fcvm-09-986078-g003.jpg
case_images: PMC9644096_01_fcvm-09-986078-g003.jpg
case_images: F3
case_images: Moreover, coronary cineangiography (Figure 2) and contrast-enhanced CT scan of the chest, as well as CCTA (Figure 3), demonstrated the anatomical course of a giant CAF clearly.
case_images: PMC9644096_02
case_images: Coronary artery cineangiography in 30  RAO (left; A) and 60  LAO (right; B) projections show a giant coronary artery (red isosceles triangles) starting from the proximal left circumflex artery and terminating in the same artery (narrow arrows).
case_images: fcvm-09-986078-g002.jpg
case_images: PMC9644096_02_fcvm-09-986078-g002.jpg
case_images: F2
case_images: TEE (2D and 3D) showed CAF courses and low-velocity flow throughout the whole cardiac cycle, which drained into the superior vena cava (Supplementary Figure 2).
case_images: Mid esophageal echocardiography in different views illustrates dilated left circumflex (light blue arrow) as well as a giant tortuous structure (fistula) (white arrow) posterior to the aorta.
case_images: fcvm-09-986078-g004.jpg
case_images: PMC9644096_02_fcvm-09-986078-g004.jpg
case_images: F4
case_images: TTE results showed the top normal size of both atria and left ventricle, normal biventricular systolic function with no PAH or significant left to right shunt (Qp/Qs = 1.2) (Figure 4).
case_images: Coronary artery cineangiography in 70  LAO (left; A) and 30  LAO (right; B) projections show a giant coronary fistula (red isosceles triangles) starting from the proximal left circumflex artery.
case_images: fcvm-09-986078-g005.jpg
case_images: PMC9644096_02_fcvm-09-986078-g005.jpg
case_images: F5
case_images: Moreover, coronary cineangiography (Figure 5) and enhanced chest CT (Figure 6) clearly demonstrated the anatomical course of a giant CAF.
case_images: Contrast-enhanced CT scan of the chest shows the proximal site of giant fistula (white arrow) originating from the left circumflex artery with drainage into the superior vena cava.
case_images: fcvm-09-986078-g006.jpg
case_images: PMC9644096_02_fcvm-09-986078-g006.jpg
case_images: F6
case_images: Moreover, coronary cineangiography (Figure 5) and enhanced chest CT (Figure 6) clearly demonstrated the anatomical course of a giant CAF.