Images in clinical medicine. Fistula connecting the left main coronary artery with the right atrium in a marathon runner

A 25-year-old asymptomatic marathon runner was found during a routine examination to have a continuous murmur that was more pronounced during systole and loudest at the aortic root on the right side of the sternum. Coronary angiography revealed a fistula connecting the left main coronary artery with the right atrium. Since we could not rule out the possibility that this abnormality could result in sudden death during overexertion, the patient was advised to reduce his level of physical activity.