A 54-year-old man presented with an episode of paroxysmal nocturnal dyspnoea on a background of increasing exertional dyspnea and was noted to have a continuous heart murmur. Transthoracic echocardiography revealed a markedly dilated left ventricle with preserved systolicfunction. Coronary angiography revealed two large fistu-lae from the circumflex artery into a complex vascular malformation emptying into the left pulmonary artery (Fig. 1). Right heart catheterisation also demonstrated a step up in oxygen saturation in the right pulmonary artery, indicating bilateral communication with the pulmonary circulation. Magnetic resonance imaging (MRI) confirmed a complex vascular malformation in the mediastinum (Fig. 2) supplied by both internal mammary arteries and large vessels arising from the coeliac axis, in addition to the coronary feeders. Symptomatic high output heart failure due to shunting through this extensive low resistance vascular bed was ameliorated by a combination of catheter-directed embolisation (Fig. 3) and surgical ligation of the malformation. Arteriovenous malformations are not uncommon, however, one of the magnitude and diverse arterial supply as described here has not previously been reported to our knowledge.
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