Heart failure due to coronary fistulas from the right and left coronary circulation into the right atrium.

A patient with a history of hypertension presented with worsening shortness of breath, fatigue, and productive cough with blood-tinged sputum. A continuous murmur was heard at the lower sternum and chest X-ray showed mild cardiomegaly. A dilated right atrium with moderately elevated pulmonary artery pressures was detected by transthoracic echocardiogram. Stress ECG did not reveal any inducible ischemia. Cardiac catheterization demonstrated an RCA aneurysm with fistula to the right atrium and a circumflex artery fistula to the right atrium, which were corrected by surgery.