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Heart. 2007 June; 93(6): 731.
PMCID: PMC1955194

The “winking” coronary sinus

A 79‐year‐old woman presented with increasing dyspnoea over 1 year. She had a history of chronic atrial fibrillation and examination showed the presence of a systolic and diastolic murmur. A dilated coronary sinus (CS) was seen on transthoracic echocardiography (panels A and B). In the parasternal short axis view, the coronary sinus could be seen “winking” in the right atrium (supplementary movie file available online at This was probably due to the dilated circular end of the CS moving in and out of the echocardiographic plane during the cardiac cycle. On coronary angiography, there was a giant right coronary artery draining through a fistula into the coronary sinus and then into the right atrium. A right‐heart study showed a rise in oxygen saturation from 55% in the inferior vena cava to 66% in the right ventricle. The Qp:Qs shunt ratio was 1:4.

figure ht95570.f1
(A) Transthoracic echocardiogram in parasternal short axis view at the level of the left ventricular outflow tract just below the aortic valve. The circular contour of the dilated coronary sinus can be seen at this level during ventricular diastole. (B) ...

This elderly patient had a congenital coronary artery fistula between the distal right coronary artery (arterial) and the coronary sinus (venous). Increased arteriovenous flow had resulted in marked dilatation of the right coronary artery and the right coronary sinus.

Treatment options include surgical ligation or use of a transcatheter closure device. The patient declined these treatment options and was managed conservatively.

Supplementary movie file available at

Copyright © 2007 BMJ Publishing Group and British Cardiovascular Society.

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