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Introduction: Coronary-cameral fistulas (CCF) are anomalous connections between one coronary artery, most commonly the right coronary, then the left or circumflex, and a cardiac chamber, most commonly the right ventricle or right atrium. However, iatrogenic CCF or coronary arteriovenous fistula can occur after coronary artery perforation. Indications for closure are significant left to right shunt, congestive heart failure due to ventricular volume overload, myocardial ischemia due to coronary steal phenomenon, prevention of endarteritis or rupture.

Case Summary: A 83-year-old female patient presented with right sided heart failure. Transthoracic echocardiography revealed unusual large fistula at tricuspid annulus, which drained into right ventricle. Cine images confirmed fistula connection to distal LAD coronary territories. Decision to treat it conservatively due to patient`s comorbidity, atypical anatomy and failure risk to close it effectively.

Conclusion: Coronary-cameral fistulas in unusual sites can be easily detected and assessed by the transthoracic echocardiography. The decision to treat is a case-by-case based on balancing the symptoms, the risk of the fistula, and the risk of complications. Careful planning of the procedure is mandatory and successful closure can be obtained by transcatheter or surgical approach.

Keywords: Fistula; Transthoracic echocardiography; Heart failure; Fistula closure devices