Cardiovascular Surgery, Vol. 9, No. 2, pp. 201–203, 2001  2001 The International Society for Cardiovascular Surgery. Published by Elsevier Science Ltd All rights reserved. Printed in Great Britain 0967-2109/01 $20.00 www.elsevier.com/locate/cardiosur PII: S0967-2109(00)00123-X CASE REPORT A case of coronary artery fistula draining into the pericardium causing hematoma Has ¸im Mutlu, M. Serdar Ku ¨c ¸u ¨ kog ˇ lu, Hakan O ¨ zhan, Erhan Kansy ´z, Servet O ¨ ztu ¨ rk and Sinan U ¨ ner Istanbul University, Institute of Cardiology, Haseki 34304, Istanbul, Turkey A 28-yr old female patient admitted to our clinic because of dyspnea and chest pain. Her transesophageal echocardiography demonstrated a huge mass on the anterolateral wall of the left ventricle causing dysfunction of the myocardium. Coronary angiography demonstrated left anterior descending artery fistula draining into the pericardial cystic mass. Hydatic cyst was suspected and ELISA and hemagglutinin tests were both negative for Echinococcus gran- ulosus. Magnetic resonance image of the heart showed a mass thought to be a hematoma inside the cyst. She underwent surgery. The cystic lesion with a pure hematoma inside, was excised, and the fistula between left anterior descending artery and the mass was ligated without any complications. To our knowledge, this is the first case of a pericardial hematoma due to a coronary artery fistula, in the English literature.  2001 The International Society for Cardiovascular Surgery. Published by Elsevier Science Ltd. All rights reserved Keywords: pericardial mass, coronary artery fistula, hematoma Introduction Coronary artery fistula is a rare congenital malfor- mation that can be complicated by intracardiac shunts, endocarditis, myocardial infarction, coronary aneurysm and sudden death. Clinical symptoma- tology depends upon the underlying anatomy and the size of the fistulous connection between the left or right side of the heart [1]. We describe here, a case of intrapericardial hematoma, a very rarely seen manifestation of coronary artery fistula, actually, the first case reported in the English medical literature to our knowledge. Case report A 28-yr old female patient admitted to our clinic with tachicardia, dyspnea, cough and chest pain. Her history revealed that she had been received antibiotic Correspondence to: H. Mutlu, S ¸ elale Mah. Du ¨den: 6 D: 22, Bahc ¸e- s ¸ehir 34900, Istanbul, Turkey. Tel.: + 90-532-2154019; e-mail: hasimmutlu@hotmail.com CARDIOVASCULAR SURGERY APRIL 2001 VOL 9 NO 2 201 treatment several weeks before due to the diagnosis of bronchopneumonia. Her complaints persisted after the treatment and her chest X-ray showed car- diomegaly. She had been referred to our clinic in order to investigate the etiology of her cardiomegaly. On admission, her blood pressure was 100/70 mmHg, pulse was 100/min. Physical examination findings were normal. ECG showed T-wave nega- tivity in derivations D1, D2, avL, avF, V2-6. Her RBC sedimentation rate was 101/h. Routine serum biochemical analyses were normal, but complete blood count revealed moderate leucocytosis and ane- mia. Transthoracic and transesophageal echocardi- ography were performed, revealing a mass on the anterolateral wall of the left ventricle pushing the myocardium and decreasing contractility (Figure 1). A hydatic cyst was suspected and diagnosis of Echin- ococcus granulosus infection was excluded with ELISA. Hemagglutination tests were negative. Cor- onary angiography demonstrated a fistula between the pericardial lesion and the diagonal branch of left anterior descending coronary artery (Figure 2). Mag- netic resonance imaging (MRI) findings revealed a hypodense pericardial cystic lesion 90×88×68 mm in