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A 74‐year‐old man with a history of atrial fibrillation and mild left ventricular impairment presented with breathlessness and ascites. Symptoms worsened despite treatment with diuretics and he eventually underwent a diagnostic ascitic tap and drain. The fluid proved exudative yet a full hepatic screen including tumour markers was normal and subsequent abdominal CT only confirmed ascites and features consistent with chronic liver disease. An echocardiogram was updated showing a mildly impaired, non‐dilated left ventricle and moderate mitral regurgitation. The right heart was dilated and readings suggested moderate pulmonary hypertension. A dilated right coronary artery (RCA) was seen in the anterior atrioventricular (AV) groove (panel A), which appeared to drain into a dilated coronary sinus and thence into the right atrium. The angiogram confirmed this and showed a normal‐sized posterior descending branch (panel B). The RCA at this point became very tortuous and drained into the coronary sinus where there was a step‐up in oxygen saturation.
Owing to the extreme tortuosity, the patient was referred for a 16‐slice cardiac CT angiogram to better delineate the anatomy. This optimally demonstrated the anatomy of the right coronary artery, posterior descending artery (PDA), fistula and coronary sinus as shown in the three‐dimensional reconstruction (panel C) and the thin maximal intensity projection slice (panel D). To determine whether the liver changes were primary or secondary, a transjugular liver biopsy was performed which demonstrated no portal hypertension and an hepatic wedge pressure consistent with the cardiac gradient. Consideration is now being given to the merits of definitive surgical correction over medical management.