Introduction: An arteriovenous (AV) fistula is an abnormal communication leading to shunting the blood from an arterial circuit with high pressure and resistance to a low resistance circuit. AV fistulas involv-ing the coronary arteries and the aorta are rare. Co-ronary angiography is the classic method used in the evaluation of these fistulas, although identification of the exact site of drainage is sometimes difficult since it is usually in a low-pressure chamber leading to contrast dilution. Echocardiography also has a limited role in the evaluation of the AV anomaly’s anatomy.

Methods: We present the case of a hypertensive, obe-se, 71 years old female, with an echocardiographic and further angiographic diagnostic from 8 years ago of an AV fi stula between the ascending aorta and the coronary sinus, with the left coronary artery (LCA) abnor-mal insertion in the fistula; the patient delayed the sur-gery, refusing the necessary additional investigations. She is under chronic treatment with an antiplatelet drug, a beta-blocker, a calcium channel blocker, a long-acting nitrate, a statin and a diuretic. She is currently accusing more often angina pain at minimal efforts.

Results: Clinical, the patient is compensated, BP=130/70 mmHg, regular HR=65 bpm; systolo-dias-tolic murmur over the entire precordium. ECG, sinus rhythm 60/min, left ventricular hypertrophy appea-rance with mixed repolarization abnormalities. Car-diac markers are within normal range. Transthoracic echocardiography shows moderate mitral insufficiency, aortic sclerosis, moderate secondary pulmonary hyper-tension, visible turbulence from the left atrium (LA) to the coronary sinus, the latter being dilated (54/44 mm), LVEF 60%, without segmental wall motion defects. The coronary angiography disclose the LAD, LCX without significant lesions, a dominant RCA with no lesions; LAD II is retrogradely loaded through collateral with competitive stream with native vessel loading; fistula between the ascending aorta and the coronary venous sinus and LA, pressional gradient at origin in the aorta of 100 mmHg; dilated coronary sinus; LCA inserts in the proximal portion of the fistula. The cardiovascu-lar surgeon requested for further angioCT/angioIRM investigations to clearly establish the anatomy of the anomaly.

Conclusions: Various AV fistulas and origin abnorma-lities of the coronary arteries may be occasionally dis-covered during the investigation of angina addressed patient by echocardiographic and angiographic exami-nations, requiring careful multi-plan analysis and 3D reconstruction by CT or MRI to determine the type and anatomy of these fistulas in order to plan surgery. The shunted blood can lead to cardiac volume overload or myocardial ischemia can occur by coronary steal, the treatment of choice of these fistulas being the sur-gical closure.