2 ︱ CASE PRESENTATION
A 50-year-old female presented to a community clinic due to fatigue after activities and was primarily diagnosed with giant left coronary artery aneurysm. On admission, she had not received surgery or special medication previously. Physical examination and electrocardiogram revealed left-inferior enlargement of the cardiac border, left ventricular high voltage, and a grade 3/6 systolic murmur could be heard in the auscultatory mitral area. Chest X-ray showed left atrioventricular enlargement and right coronary calcification. Transthoracic echocardiography (TTE) indicated a 7.1×7.4 cm cyst-like aneurysm at the upper back of the left atrium, which originating from the left coronary artery, detouring to the left posteriorly, and breaking into the right atrial appendage; accompanied by moderate mitral and tricuspid regurgitation (FIGURE 1). Concurrently, the left coronary artery ostium dilated up to 2.8 cm, and the possibility of RASA should be further precluded. Then cardiac three-dimensional computed tomography (3D-CT) was recommended to reconstruct the aneurysm. Cardiac 3D-CT revealed a RASA of the left coronal sinus and an aneurysm-like fistula connecting the left main coronary artery with the right atrium, squeezing the right pulmonary vein and left atrium (FIGURE 2). During operation, transesophageal echocardiogram (TEE) and surgical vision confirmed these findings (FIGURE 3, VIDEO 1-3). Under cardiopulmonary bypass, the patient underwent RASA repair, coronary artery bypass grafting (great saphenous vein graft to left anterior descending and circumflex branches), mitral and tricuspid valvuloplasty, and temporary pacemaker implantation. Following operation, TEE confirmed that there was no flow in the right atrial fistula, and the aneurysm in the posterior wall of the left atrial was collapsed. The patient was fully recovered and discharged home at 14th day after operation.