Giant Circumflex Coronary Artery Fistula to the Superior Vena Cava in Patient With Multiple Valvular Disease

3 68-year-old man was admitted to our hospital with a history of dyspnea and considerable fatigue with xercise. Transthoracic echocardiography showed severe itral, aortic, and tricuspid regurgitation. The patient nderwent coronary angiography before surgery, which evealed a giant coronary artery fistula arising from the ircumflex artery (Fig 1). A multi-sliced computed tomoraphic scan was performed to delineate the fistula and ocalize its drainage. Three-dimensional reconstruction howed a tortuous course with multiple loops in the ateral wall (Fig 2) that seemed to end in the pulmonary rtery. Intravenous contrast enhancement allowed the ocation of the drainage orifice in the superior vena cava, ear the right atrium. The patient was operated on through a midline ternotomy. On opening the pericardium, the dilated essel (arrow) was seen to course from the lateral wall f the left ventricle through the transverse sinus, and it nished at the superior vena cava (Fig 3). It measured 5 mm in diameter. Cardiopulmonary bypass was stablished (with bi-caval cannulation) after occlusion f the fistula near its drainage. After mitral valve epair, aortic valve replacement, and tricuspid ring nnuloplasty, the superior vena cava was opened and