[Anomalous origin of right coronary artery].

Aroutine transthoracic echocardiogram (TTE) was performed in a 72-year-old woman with signs and symptoms of heart failure. The 2D TTE images revealed an enlarged right coronary artery (RCA) with reverse flow draining into the pulmonary trunk and the presence of dilated septal vessels (Figure 1). Coronary angiography and MRI confirmed the previous echocardiographic findings (Figures 2 to 4). Accordingly, surgical ligation of the RCA was carried out. Before ligation, an intraoperative transesophageal echocardiogram and direct visualization revealed grossly dilated coronary arteries (14 to 16 mm in diameter) and numerous fistulas over the anterior surface of the left ventricle and next to the right atrioventricular groove (Figures 5 and 6). The RCA was ligated proximally, and a bypass with an inverted saphenous vein was constructed between the aorta and the RCA just distal to the ligation. Sequential Doppler flow velocity assessment of the RCA before ligation and of the saphenous vein graft disclosed an increase in diastolic velocity and a reduction in systolic and retrograde flow velocity after RCA ligation (Figure 7). The postoperative course was uncomplicated, and the patient was discharged on postoperative day 7.