Diagnosis of anomalous left coronary artery by Doppler color flow mapping: distinction from other causes of dilated cardiomyopathy

Anomalous Left Coronary Artery Arising from the Pulmonary Artery (ALCAPA): The Critically Important Role of Color Flow Doppler in Identifying a Rare Intramural Course

•ALCAPA must be considered in an infant with ischemia and/or heart failure. •A rare variant with intramural aortic course may appear normal on 2D echo. •Retrograde color flow in the LCA is highly suspicious for this lesion. •Ambiguous cases will benefit from multimodality imaging via catheterization or CT. •Early recognition may lead to lifesaving surgical correction.

Evaluation of Anomalous Coronary Arteries from the Pulmonary Artery

Objective

This study evaluated clinical and diagnostic findings, treatment methods, and follow-up of cases of anomalous coronary arteries from the pulmonary artery.

Methods

The study included all cases diagnosed with anomalous coronary arteries from the pulmonary artery between January 2012 and January 2016. Data from patients’ demographic characteristics, electrocardiography, echocardiography, angiographic findings, operation, intensive care unit stay, and follow-up were evaluated.

Results

The study included 12 patients (8 male, 4 female), 10 with anomalous left coronary artery from the pulmonary artery (ALCAPA) and 2 with anomalous right coronary artery from the pulmonary artery (ARCAPA). Median age at diagnosis was 4 months (range, 1 month - 10 years old) and median weight was 5.5 kg (range, 3-30 kg). The most common complaints were murmur (n=7) and respiratory distress (n=5). In 4 cases, the initial diagnosis was dilated cardiomyopathy. Electrocardiographs were pathologic in all cases. Echocardiographic examination revealed medium to severe mitral valve regurgitation in 4 cases and reduced (< 40%) ejection fraction in 6 patients. Of the 12 patients, 8 underwent direct implantation of the left coronary artery into the aorta, 2 underwent implantation of the right coronary artery into the aorta, and the remaining 2 underwent a Takeuchi procedure. There were no early mortalities. Median hospital stay was 20 days (range, 5-35 days). Median follow-up duration was 18 months (range, 5-36 months), and no cases required further surgery during follow-up.

Conclusions

Anomalous coronary arteries from the pulmonary artery can be successfully repaired providing there is early diagnosis and effective, appropriate intensive care unit follow-up. Therefore, coronary artery origins should be evaluated carefully, especially in cases with dilated cardiomyopathies.

[Late discover of a coronaro-pulmonary fistula]

Anomalies of the coronary arteries mainly concern a pediatric population, bringing together a wide range of defects. In adults, the evolution is linked to the hemodynamic consequences of fistula. Several therapeutic options have been proposed such as surgery or embolization. We report the case of a 55 years old patient addressed because of dyspnea secondary to aortic insufficiency. The preoperative assessment shown the coexistence of coronary abnormality corresponding to a coronaro-pulmonary fistula. This type of coronary anomaly is rarely described in the adult population, because of its consequences secondary to the closure of the foramen ovale, resulting in angina symptoms in childhood. Without treatment, mortality from this type of malformation is important (90%).

Neonatal ventricular fibrillation and an elusive ALCAPA: things are not always as they seem

An anomalous left coronary artery from the pulmonary artery (ALCAPA) is a rare congenital cardiac condition that typically presents with poor feeding and failure to thrive from progressive myocardial ischaemia. Previous reports of ALCAPA presenting with ventricular fibrillation (VF) have suggested a causative relationship. In this case, we present a neonate with VF without apparent cause after an extensive evaluation. Following implantable cardioverter-defibrillator placement for presumed idiopathic VF, at which time she also underwent surgical ligation of a patent ductus arteriosus (PDA), the neonate developed haemodynamic instability that ultimately was found to be due to ALCAPA. Numerous echocardiograms had missed the ALCAPA in the setting of mildly elevated pulmonary artery pressure. We discuss the limitations of current ultrasound technology in diagnosing ALCAPA in the setting of pulmonary hypertension and explain why the relationship between this patient's diagnosis of ALCAPA and her episode of VF is not clearly causative.

Imaging of congenital coronary artery anomalies

Imaging of the coronary arteries is an important part of the evaluation of children with congenital heart disease and isolated congenital coronary artery anomalies. Echocardiography remains the main imaging modality and is complemented by MRI and CT angiography in the older or difficult-to-image child. We review echocardiography, MRI, and CT angiography for coronary artery imaging, with emphasis on techniques. The clinical implications of isolated congenital coronary artery anomalies are also addressed, along with a discussion about the current consensus on optimal management of these anomalies.

Noninvasive methods of accurately diagnosing in children anomalous origin of the left coronary artery from the pulmonary trunk

BACKGROUND

Anomalous origin of the left coronary artery from the pulmonary trunk is a rare congenital heart defect. Cardiac catheterization remains the standard means of diagnosis. Our purpose in this study is to emphasize the importance of assessing the electrocardiogram when making the diagnosis, in addition to taking note of transthoracic echocardiographic findings. We also analyzed the sensitivity of each parameter under investigation.

METHODS AND RESULTS

Between June, 1999, and March, 2007, we studied 9 patients, 6 males and 3 females, with a mean age of 3.02 years, in whom anomalous origin of the left coronary artery from the pulmonary trunk was suspected subsequent to transthoracic echocardiographic examination. We examined their electrocardiograms, and undertook cardiac catheterization. In all patients, the transthoracic echocardiogram had shown retrograde flow into the pulmonary trunk, with the left coronary artery arising from pulmonary trunk, along with a dilated right coronary artery, or intercoronary collateral vessels. In 8 patients, the electrocardiogram showed deep Q wave in leads I and aVL, with depression of the ST segments over lead V4 through 6, or inversion of the T waves in leads I, II, and aVL. In the remaining patient, the electrocardiogram showed incomplete right bundle branch block. Later, cardiac catheterization confirmed the diagnosis in 8 patients, but the other patient was shown to have the right coronary artery arising from the pulmonary trunk.

CONCLUSIONS

By combining transthoracic echocardiography with study of the electrocardiogram, it is possible to provide accurate evaluation of anomalous origin of the left coronary artery from the pulmonary trunk.

An infant with respiratory distress

Infants with previously undiagnosed cardiac conditions may present to the emergency department with nonspecific signs and respiratory symptoms. These patients may be erroneously diagnosed as having bronchiolitis. We report a 2-month-old female infant who presented with respiratory distress and showed no improvement with nebulized albuterol treatment. This infant was found to have anomalous origin of the left coronary artery from the pulmonary artery.

[Fulminant myocarditis presenting like acute myocardial infarction in a 6-year-old girl]

Acute myocarditis is a rare inflammatory cardiac disease in children with potentially fatal issue. Clinical findings are very variable from nausea and vomiting to acute cardiovascular collapse. The cardiac function can be reversible with circulatory support. We report the case of a 6-year-old girl with ECG changes like myocardial infarction and diagnosis of fulminant myocarditis. She developped rapidly a cardiogenic shock and died before treatment with mechanical circulatory support.

Congenital Coronary Artery Abnormalities in Children

After a significant coronary artery abnormality is recognized in a pediatric patient, surgery or appropriate transcatheter intervention should be performed. The risk of fatality from a congenital coronary abnormality far outweighs the small risks of surgical or transcatheter intervention. Angiography, although considered the state-of-the-art method of diagnosis, has significant spatial limitations and is not always diagnostic of aberrant coronary origins from the contralateral aortic sinus. In the hands of an experienced coronary imager, color flow Doppler echocardiography is one of the best diagnostic tools for congenital coronary abnormalities. Symptoms of a coronary abnormality vary from none to a sudden coronary event that may result in death. Awareness of subtle as well as obvious symptoms is essential for a timely intervention. Surgical or transcatheter intervention in an asymptomatic child with a coronary abnormality is controversial, but it is becoming more acceptable due to a better understanding of the risks involved in unrepaired congenital coronary abnormalities. Surgical reimplantation is the treatment of choice for a patients with a pulmonary origin of a coronary artery. Surgical unroofing of the intramural segment is preferable in an aberrant coronary origin from the contralateral aortic sinus. Surgical enlargement of a stenotic ostium is recommended for ostial stenosis. Transcatheter coil embolization is becoming the treatment of choice of large coronary artery fistula.

Cardiac imaging in a patient with anomalous origin of the left coronary artery from the pulmonary artery--a case report

Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) is an uncommon congenital heart disease and has a high mortality rate in infancy. However, myocardial ischemia does not develop until adolescence or adulthood in about 10% of patients. Moreover, the diagnosis of ALCAPA is often difficult in cases without heart murmur or cardiac symptoms. The authors report the case of a 31-year-old man with ALCAPA. He was admitted to the hospital for evaluation of mild shortness of breath at exercise, but he had no typical chest symptoms due to myocardial ischemia or heart failure until age 31 and he had no heart murmur. Moreover, electrocardiogram did not show an old myocardial infarction or myocardial ischemia. Therefore, the authors did not suspect ALCAPA until they performed transthoracic echocardiography and exercise-stress single photon emission computed tomography (SPECT) with Tc-99m-tetrofosmin. The final diagnosis was established from the results of coronary arteriography. In the present case, a transthoracic echocardiogram showed abnormal coronary circulation, and exercise-stress SPECT revealed reversible myocardial ischemia. Transthoracic echocardiography and myocardial SPECT imaging could be a useful noninvasive tools for diagnosing the ALCAPA.

Arcade mitral valve and anomalous left coronary artery originating from the pulmonary artery

The use of color Doppler interrogation significantly improves accuracy in the evaluation of coronary artery anatomy. This was demonstrated in a patient in whom the left coronary artery originated from the posterior and medial aspect of the pulmonary artery, a particularly difficult coronary anomaly to detect by 2-dimensional imaging. In addition to the coronary artery anomaly, this patient also had an arcade mitral valve.

Transesophageal echocardiography (TEE) in the evaluation of the coronary arteries

With technical advancements, including high frequency, multiplane transducers, digital acquisition and display, and left-sided contrast agents, TEE is emerging as a promising method for evaluating coronary artery disease. Visualization of proximal coronary artery stenoses and coronary artery anomalies is already possible. Research studies using TEE measurement have contributed to understanding coronary artery physiology and may prove to be a valuable clinical tool in the future.

Pediatric echocardiography: applications and limitations

Echocardiography is an extraordinarily useful imaging technique in fetuses, infants, children, and adolescents. Recent technologic innovations have expanded its versatility in the pediatric population. However, limited societal resources, limitations inherent to ultrasound imaging, and numerous imaging options even within the field of pediatric echocardiography necessitate the discriminate and thoughtful use of echocardiography in children. The clinical assessment remains a critical prelude to echocardiographic examination of the pediatric cardiovascular system.

Congenital coronary artery abnormalities

Congenital coronary artery abnormalities are rare and account for approximately 0.1 to 2% of congenital heart defects. They may pose significant risk of mortality or morbidity to the patient. The pediatrician and the pediatric cardiologist should be aware of their subtle but very serious presentations and diagnostic steps to be undertaken to pinpoint the diagnosis. Prevention of serious complications from these abnormalities can be achieved by making the appropriate diagnosis and performing timely surgical intervention. This review will discuss the most common congenital coronary artery abnormalities and their management.

Dobutamine stress echocardiography in the assessment of suspected myocardial ischemia in children and young adults

In 67 studies in 43 children with suspected coronary artery disease, dobutamine stress echocardiography was safe and accurate in diagnosing coronary insufficiency. The efficacy and safety of dobutamine echocardiography make it the ideal test for diagnosing myocardial ischemia in children.

Stenosis at the origin of an anomalous left main coronary artery arising from the pulmonary artery in a symptom-free adolescent girl: transesophageal echocardiographic findings

We report an unusual finding of ostial stenosis of an anomalous left main coronary artery originating from the pulmonary artery in a symptom-free adolescent girl. Transesophageal echocardiography with Doppler color imaging correctly identified all of the salient features of this anomaly including proximal stenoses of the right and left coronary arteries. These findings were subsequently confirmed at cardiac catheterization.

Doppler color flow echocardiography: indispensable application to congenital heart disease

Doppler color flow imaging has become indispensable in the diagnosis and management of patients with congenital heart disease. Certain defects may not be possible, or may be very difficult to diagnose by two-dimensional echocardiography alone. Such examples include multiple ventricular septal defects, anomalous pulmonary venous connection, coronary artery malformations, and the hypertensive patent ductus arteriosus. Additionally, color flow Doppler echocardiography significantly provides additional information, and reduces the time for fetal and transesophageal echocardiographic studies. Doppler color flow imaging has become an essential part of the echocardiographic examination. Experience has broadened the use of this important technological advance, with anticipation of an ever expanding future for its clinical application.

Differentiating anomalous left main coronary artery originating from the pulmonary artery in infants from myocarditis and dilated cardiomyopathy by electrocardiogram

Anomalous left main coronary artery (ALMCA) originating from the pulmonary artery is an important cause of morbidity from heart failure and mortality in infants. Discriminating ALMCA from myocarditis or other forms of dilated cardiomyopathy (DC) in infants is critical for proper early management of this treatable disease. This study was performed to characterize electrocardiographic (ECG) patterns in infants with ALMCA, and to identify features that would allow differentiation of these infants from those with myocarditis/DC. Presenting electrocardiograms from 28 patients with ALMCA < 2 years of age were analyzed for 103 variables, and compared with electrocardiograms from 28 aged-matched infants with myocarditis/DC using the t test, Fisher's exact test, and discriminant analysis using stepwise logistic regression techniques. ECG findings characteristic of infants with ALMCA were confirmed, including deep (> or = 3 mm) and wide (> or = 30 ms) Q waves and a QR pattern in at least 1 of the following leads: I, aVL, V5 to V7. Also, the complete absence of Q waves from leads II, III, and aVF in all infants with ALMCA was noted. These and other ECG patterns were more common in infants with ALMCA than in those with myocarditis/DC (p < 0.05), but were also noted in some patients with myocarditis/DC. Stepwise logistic regression analysis identified 3 ECG variables that best discriminated ALMCA from myocarditis/DC, including Q wave width (w) in lead I, and Q-wave depth (d) and ST-segment amplitude (s) in lead aVL.(ABSTRACT TRUNCATED AT 250 WORDS)

Acute myocardial-infarction-like findings with myocarditis in infancy. A case report

A four-and-a-half-month-old infant suffered sudden circulatory collapse early in the course of a brief febrile illness. The electrocardiogram initially appeared normal; an abrupt change indicative of extensive myocardial infarction occurred following stabilization. Coronary arterial anatomy and flow by echocardiography and angiography were normal except for the finding of single origin of the entire coronary system from the left sinus of Valsalva. Gallium 67 myocardial imaging was positive for an inflammatory process, and the diagnosis of myocarditis was supported. This is the first case, to the authors' knowledge, of myocarditis simulating myocardial ischemia in an infant of an age in which anomalous origin of the left coronary artery from the pulmonary artery is a recognized cause for myocardial infarction.

Intercoronary collateral flow detected by Doppler colour flow mapping is an additional diagnostic sign in children with anomalous origin of the left coronary artery from the pulmonary artery

Intercoronary collateral flow within septal collaterals was detected by colour-coded Doppler echocardiography in three children with anomalous origin of the left coronary artery from the pulmonary artery. In each of the three patients angiography confirmed the presence of septal collaterals.

The role of transesophageal echocardiography in identifying anomalous coronary arteries

BACKGROUND

The study objective was to evaluate the role of transesophageal echocardiography in identifying the origin of anomalous coronary arteries and confirming their course in relation to the great vessels. The diagnosis of coronary anomalies is made by angiography. The anomalous left main artery with a course between the pulmonary artery and the aorta has been associated with myocardial infarction and sudden death. The course of these anomalous coronary arteries is difficult to demonstrate by angiography alone.

METHODS AND RESULTS

Nine patients with angiographically confirmed anomalous coronary arteries were studied by transesophageal echocardiography with color flow Doppler. The abnormal origin of the anomalous coronary arteries was confirmed by transesophageal echocardiography in all nine patients. In four patients, the left main coronary artery originated from the right sinus of Valsalva. In all of these patients, transesophageal echocardiography demonstrated the course of the anomalous left main coronary artery between the aorta and pulmonary artery better than angiography. Other anomalies that were visualized included two patients with origin of the right coronary arteries from the left aortic sinus, one patient with origin of the left anterior descending from the right sinus, one patient with origin of circumflex from the right sinus, and one patient with origin of the left main coronary artery from the pulmonary artery.

CONCLUSIONS

Transesophageal echocardiography is a useful noninvasive test for diagnosing anomalous origin of the coronary arteries. Furthermore, it is a valuable adjunct to angiography in demonstrating the abnormal course of the left main coronary artery interposed between the aorta and the pulmonary artery, a potentially life-threatening entity.

An unusual coronary artery origin in a patient with anomalous left coronary artery

In the typical patient with anomalous left coronary artery (ALCA) arising from the pulmonary artery, the left coronary artery arises from within the left or posterior pulmonary sinus. We report a case of ALCA in which the left coronary arose medially from the pulmonary artery above the commissure separating the right and posterior pulmonary sinuses. This unusual origin highlighted some of the problems with the noninvasive diagnosis of ALCA.

Long-term follow-up after two coronary repair of anomalous left coronary artery from the pulmonary artery

A retrospective analysis of ten patients with anomalous left coronary artery arising from the pulmonary artery operated between 1979 and 1990 was undertaken. All presented with evidence of left ventricular dysfunction and "ischemic" mitral regurgitation. Surgical repair consisted of an aortopulmonary tunnel (Takeuchi) procedure in eight and direct left coronary artery reimplantation in two. Two patients required postoperative support with a left ventricular assist device. There were no operative or late deaths (CL 0% to 17%) for a follow-up of over 670 patient months. All patients are in New York Heart Association Class I or II, though two patients are still receiving anticongestive medications. One patient has required further surgery for pulmonary artery stenosis, and another has had a mitral valve replacement because of severe mitral regurgitation. One additional patient has moderate-to-severe residual mitral regurgitation and two have a trivial left coronary to main pulmonary artery fistula. All have a patent, nonstenotic left coronary artery and much improved left ventricular function and perfusion as assessed by echocardiography, thallium scan, gated blood pool scan, and angiography. There have been no documented arrhythmias, clinically or on Holter monitoring. The ECGs have shown resolution or improvement of the initial changes of ischemia/infarction in all patients. Chest X-rays have shown normalization of cardiothoracic ratio in eight of ten patients. Excellent early and late results can be achieved following timely surgical repair. Marked improvement in left ventricular function has been observed in patients with poor preoperative left ventricular function, even in the presence of extensive ischemia/infarction.