Magnetic resonance imaging of an anomalous origin of the left coronary artery from the pulmonary artery

Magnetic resonance imaging of Bland-White-Garland syndrome--a case of anomalous origin of the left coronary artery from the pulmonary trunk in a 22-year-old woman

Selective right coronary angiography in a 22-year-old woman demonstrated an enormous right coronary artery, with the contrast medium opacifying to the left coronary artery through a well-developed collateral circulation and draining into the pulmonary artery. The diagnosis of anomalous origin of the left coronary artery from the pulmonary trunk [also known as Bland-White-Garland (BWG) syndrome] was thus established. Magnetic resonance imaging (MRI) showed a dilated right coronary artery arising from the aorta, the left coronary artery from the pulmonary trunk but not from the aorta, and well-developed channels in the interventricular septum. MRI could be a useful tool for diagnosing anomalous origin of the left coronary artery from the pulmonary trunk.

Magnetic resonance angiography of anomalous coronary arteries. A new gold standard for delineating the proximal course?

BACKGROUND

The clinical significance of anomalously originating coronary arteries depends on their proximal course. Diagnosis of this course by conventional x-ray coronary angiography alone may be equivocal. We postulated that with fast magnetic resonance (MR) angiography, accurate detection of anomalous coronary arteries and unambiguous delineation of their proximal course is feasible.

METHODS AND RESULTS

In a selected group of 38 patients, 19 of them having an anomalously originating coronary artery, a fast MR angiographic technique was used to study the proximal coronary anatomy. Blinded analysis of randomly ordered MR studies was performed independently by two observers. Both origin and proximal course of the coronary arteries were defined. Two cardiologists reviewed all x-ray coronary angiograms. After the separate analyses, a final consensus result was defined for each patient. In 37 patients, successful MR coronary angiography could be performed. Interobserver agreement for determining both origin and proximal course was 100%. An x-ray coronary angiogram was available in 36 patients. In 3 patients (all with an anomalous left main coronary artery originating from the right aortic sinus), there was disagreement about the proximal course between the results of MR and x-ray coronary angiography. Review of these cases demonstrated that MR angiography had unambiguously visualized the proximal coronary artery course, whereas the results of x-ray angiography had been equivocal. Thus, sensitivity and specificity for detecting anomalous coronary arteries and delineating their proximal course were 100%.

CONCLUSIONS

These data suggest that fast MR angiography is highly accurate in determining the origin and delineating the proximal course of anomalous coronary arteries, even in those cases in which x-ray coronary angiographic diagnosis is difficult or even erroneous.

Diagnostic considerations in patients with suspected coronary artery anomalies

The diagnosis of coronary artery anomalies requires a high index of suspicion during the history and physical examination. Nonspecific presentations are common, although dramatic presentations such as myocardial infarction or aborted sudden death will occur. Typically the results of the physical examination and ECG and the chest x-ray film are normal except with ALCAPA or coronary-artery fistulas. Screening studies such as exercise stress testing have low sensitivity, and a negative evaluation does not rule out the presence of a significant anomaly. These important limitations must be considered. Echocardiography is a practical and frequently diagnostic test if specific attention is paid to the coronary arteries. This examination should be performed in most patients with suspect symptoms. Other noninvasive techniques such as nuclear and cine MRI cardiac imaging may become increasingly important, but their current use is anecdotal. Cardiac catheterization remains the gold standard; however, recognition of important clues and specific angiographic views are required to fully delineate many anomalies.