Unroofed Coronary Sinus: Incidentally Detected on Pulmonary Computed Tomography Angiography

A 56-year-old female presented to the Emergency Department with palpitations and shortness of breath. The patient had a history of hypertension, diabetes mellitus, and hyperthyroidism. The patient's body temperature was 36.7°C and blood pressure was 125/80 mmHg. On electrocardiogram, negative T-waves were observed in the right precordial leads. Laboratory analysis revealed low haemoglobin value (11.4 g/dL; reference, 12–14 g/dL), high fasting blood glucose (185 mg/dL; reference, 74–106 mg/dL), and elevated D-dimer level (788 ng/mL; reference, <280 ng/mL). Other laboratory parameters, including C-reactive protein and high-sensitivity troponin I, were within normal limits. A chest radiograph revealed cardiomegaly, pulmonary artery dilatation, and pulmonary vessel cephalisation (Figure 1A). The patient underwent pulmonary computed tomography angiography (CTA) with suspicion of a pulmonary embolism, and the CTA showed dilatation of the right heart chambers and pulmonary arteries without pulmonary embolism. Moreover, CTA revealed a persistent left superior vena cava (PLSVC) draining into the left atrium, dilatation of the coronary sinus (CS), and complete communication between the CS and left atria, consistent with unroofed CS (UCS) (Figures 1B-F). Transthoracic echocardiography (TTE) revealed left ventricular systolic dysfunction (ejection fraction of 48%) and severe dilatation in the right heart chambers, with mid-systolic notching in the pulmonary artery. Moreover, TTE revealed a tricuspid annular systolic excursion of 10 mm, systolic pulmonary artery pressure of 75 mmHg, and inferior vena cava size 24 mm and collapsibility <50%. The patient underwent right heart catheterisation, and the pulmonary artery pressure was 44 mmHg. The patient was followed up with medical treatment with a diagnosis of pulmonary hypertension.