Complementary role of transoesophageal echocardiography to coronary angiography in the assessment of coronary artery anomalies

Anomalous Origin of the Right Coronary Artery: An Uncommon Presentation

The anomalous origin of the coronary artery is a relatively uncommon condition with a variant incidence depending on the modality of the imaging techniques such as transesophageal echocardiography (TEE), computed tomography angiography (CTA), magnetic resonance angiography (MRA), or invasive coronary angiography (ICA). The importance of diagnosing ectopic coronary artery origin comes from its possible relation to sudden cardiac death (SCD) cases in young populations. The anomalous origin of the coronary artery could cause myocardial ischemia and fibrosis; this would, in turn, increase the chances of fatal ventricular arrhythmias. In this report, we present a 40-year-old male, incidentally found to have persistent tachycardia and a gradually decreasing left ventricular ejection fraction (LVEF). He denied any symptoms or changes in his baseline, unlimited, functional capacity. However, his records were remarkable for persistent tachycardia over more than six months, raising concerns about tachyarrhythmia-induced cardiomyopathy related to his anatomical variations. We also discussed the guideline-directed therapeutic option for the abnormal origin of the coronary artery as per current guidelines.

Anomalous Aortic Origin of a Coronary Artery From the Inappropriate Sinus of Valsalva

Anomalous aortic origin of a coronary artery (AAOCA) from the inappropriate sinus of Valsalva is increasingly recognized by cardiac imaging. Although most AAOCA subtypes are benign, autopsy studies report an associated risk of sudden death with interarterial anomalous left coronary artery (ALCA) and anomalous right coronary artery (ARCA). Despite efforts to identify high-risk ALCA and ARCA patients who may benefit from surgical repair, debate remains regarding their classification, prevalence, risk stratification, and management. We comprehensively reviewed 77 studies reporting the prevalence of AAOCA among >1 million patients, and 20 studies examining outcomes of interarterial ALCA/ARCA patients. Observational data suggests that interarterial ALCA is rare (weighted prevalence = 0.03%; 95% confidence interval [CI]: 0.01% to 0.04%) compared with interarterial ARCA (weighted prevalence = 0.23%; 95% CI: 0.17% to 0.31%). Recognizing the challenges in managing these patients, we review cardiac tests used to examine AAOCA and knowledge gaps in management.

Single coronary artery anomaly: Report of an extremely rare variation

A 43-year-old man presented with unstable angina. Coronary angiography revealed a single coronary artery originating from the left sinus of Valsalva, giving rise to a left main stem trifurcating to the left anterior descending artery, left circumflex artery, and an anomalous right coronary artery. The anomalous right coronary artery had a retroaortic course and significant proximal tubular stenosis which was stented. The coronary anomaly and abnormal course was confirmed by transesophageal echocardiography. The patient was symptom-free at one-year follow-up. This anomaly does not predispose to accelerated atherosclerosis, and the premature atherosclerosis in our patient was probably due an unhealthy lifestyle.

Coronary Artery Fistula-Associated Endocarditis: Report of Two Cases and a Review of the Literature

Coronary artery fistulae (CAF) are rare congenital anomalies and reported to have an incidence of 0.1-0.2% of all coronary angiograms. An association between fistulae and nonatherosclerotic coronary artery aneurysms is even more rare. In childhood, patients are mostly asymptomatic; however, patients older than 20 years old may present with signs of infective endocarditis, myocardial ischemia, congestive heart failure, and aneurysm rupture. CAF are typically identified by coronary angiography; however, there are some limited studies showing that transesophageal echocardiography (TEE) can also be useful in identifying CAF. Here we report two cases of endocarditis secondary to congenital coronary artery fistulae draining into either a cardiac cavity or a coronary sinus, which were detected by TEE. Vegetations were found at the site of the fistulae drainage. Management for young patients is either percutaneous or surgical intervention. For elderly patients with multiple comorbidities, conservative treatment is another option. In these two cases, treating endocarditis with proper antibiotics and supportive treatment, the patients' conditions improved significantly.

Coronary anomalies encountered in the acute setting: an imaging review

A broad spectrum of congenital coronary anomalies may be discovered on imaging and sometimes in the emergency setting on computed tomography (CT). Most coronary artery anomalies are of academic interest; however, a minority can cause morbidity and mortality and symptoms such as angina, myocardial infarction, or arrhythmias. These anomalies are usually discovered as an incidental finding on CT examinations as part of the diagnostic workup for other pathology or on dedicated coronary computed tomography angiography (CCTA) as part of the evaluation for a coronary cause of chest pain. The purpose of this pictorial review is to demonstrate the types of coronary anomalies and to enhance the clinicians' understanding of the imaging classifications and clinical implications.

The incidence of coronary anomalies on routine coronary computed tomography scans

OBJECTIVE

This study aimed to assess the incidence of coronary anomalies using 64-multi-slice coronary computed tomography (MSCT).

METHODS

The diagnostic MSCT scans of 745 consecutive patients were reviewed.

RESULTS

The incidence of coronary anomalies was 4.96%. The detected coronary anomalies included the conus artery originating separately from the right coronary sinus (RCS) (n = 8, 1.07%), absence of the left main artery (n = 7, 0.93%), a superior right coronary artery (RCA) (n = 7, 0.93%), the circumflex artery (CFX) arising from the RCS (n = 4, 0.53%), the CFX originating from the RCA (n = 2, 0.26%), a posterior RCA (n = 1, 0.13%), a coronary fistula from the left anterior descending artery and RCA to the pulmonary artery (n = 1, 0.13%), and a coronary aneurysm (n = 1, 0.13%).

CONCLUSIONS

This study indicated that MSCT can be used to detect common coronary anomalies, and shows it has the potential to aid cardiologists and cardiac surgeons by revealing the origin and course of the coronary vessels.

Coronary artery fistula

Although coronary arterial fistula is rare, it is one of the most common among the coronary artery anomalies. Coronary arterial fistula most commonly affects the right side of the heart. It may occur isolated or along with congenital heart diseases. Angiography remains the best investigation for diagnosing the disease. Unless very large and hemodynamically significant, it is usually asymptomatic in younger patients. With increasing age, symptoms begin to appear, and the incidence of complication rises. Treatment by transcatheter or surgical closure gives the best results, provided this is performed early in the course of the disease. This review was prepared by searching the terms "coronary artery fistula," "coronary cameral fistula," "surgical management of coronary arterial fistula," "MDCT in coronary artery fistula," and "multiple coronary artery fistulae" in Google Scholar, PubMed, and PubMed Central and exploring the related articles shown on the side of page.

Transesophageal echocardiography, more than a diagnostic tool: use during surgical ligation of coronary artery fistulae - a case report

Coronary artery fistulae (CAF) are an infrequent coronary abnormality. Herein, we describe the use of intraoperative transesophageal echocardiography (TEE) in the treatment of CAF. A 61 year-old woman presented with chest pain and symptoms consistent with unstable angina. Subsequent coronary angiography revealed the presence of 2 CAF, one extending from the left anterior descending artery to the pulmonary artery (PA) and the other extending from the proximal right coronary artery to the PA. Surgical ligation of the CAF without coronary bypass was arranged. Intraoperative TEE was successfully employed to localize the CAF, monitor fistula blood flow and heart wall motion, and confirm successful ligation. The patient recovered without complications. This case highlights the utility of intraoperative TEE during ligation of CAF.

Giant coronary artery aneurysm with coronary arteriovenous fistula draining into the coronary sinus

A 77-year-old patient suffering from a giant right coronary artery aneurysm with coronary arteriovenous fistula was admitted to our hospital. The fistula could not be documented preoperatively by computed tomography or coronary angiography but was documented intraoperatively by transesophageal echocardiography (TEE). However, TEE was unable to visualize the draining site of the fistula. Direct palpation by the surgeon ultimately confirmed that the fistula was draining into the coronary sinus. The fistula was closed and the volume of the aneurysm reduced by partial resection. The postoperative course of the patient was uneventful. Giant aneurysms occasionally displace cardiac structures. In such cases, combined imaging technologies, including TEE, may be needed for precise assessment of the giant aneurysm and fistula.

Anomalous origin of the coronary arteries in children: diagnostic role of three-dimensional coronary MR angiography

When the anomalous origin of coronary arteries (AOCA) is suspected in children (especially athletes), due to signs and symptoms of myocardial ischemia or on the basis of echocardiographic assessment, three-dimensional coronary magnetic resonance angiography (3D-CMRA) can be proposed for the fine morphological evaluation of coronary branches anatomy and course. We tested the diagnostic potential of CMRA angiography in a prospective study on AOCA in young patients. Between July 2005 and June 2008, 15 patients aged 6-29 years (mean age, 13.5 years+/-5.6 S.D.; median, 14) with clinical and echocardiographic suspicion of AOCA underwent CMRA (1.5 T), 3D whole-heart, free-breathing technique, without the use of contrast medium and beta-blockers, with a mean examination time of 30 min. We acquired a second scan of all patients to ameliorate the quality of the acquisition and to improve our experience. AOCA was confirmed by 3D-CMRA in 8 out of 15 cases (53%) and three different anatomical variants were demonstrated, that is, ectopic origin of the left circumflex artery arising from the right coronary artery with retro-aortic course in four cases, single coronary artery arising from the right sinus of Valsalva with interarterial course in one case, ectopic right coronary artery arising from the left sinus of Valsalva with interarterial course in one case; in two patients without anomalies of origin of the coronary arteries, elongated LMCA with angulation of the proximal segment of the left circumflex artery was present. When AOCA is suspected particularly in children (especially athletes), CMRA without the use of contrast medium is an effective diagnostic technique, which is useful to clarify the spatial position of the anomalous course of the main coronary branches in order to suggest the most convenient management of the disease. CMRA does not need contrast medium, needles, and beta-blockers; is repeatable in the same examination without the exposure to X-rays; allows a parent to stay near the child; and needs low collaboration in low-stress conditions.

Coronary arteriovenous malformation, as imaged with cardiac computed tomography angiography: A case series

INTRODUCTION

Coronary Arteriovenous Malformations (AVM) can lead to various cardiovascular events. The severity of clinical manifestation depends on the degree of the malformation. The significance of major arterial shunt is that they can deprive the myocardium of the necessary amount of blood, leading to myocardial ischemia, and potentially tachycardia, left ventricular dilatation and heart failure secondary to increased stroke volume and cardiac output. Cardiac computed tomography (CCT) has proven to be a good non-invasive diagnostic tool in the detection of coronary Arteriovenous Malformations.

CASE PRESENTATION

We include 4 patients, who presented with various symptoms in relation to the coronary Arteriovenous Malformations. Diagnostic confirmation was made non-invasively using multi-row detector cardiac computed tomography (MDCT).

CONCLUSION

Coronary Arteriovenous Malformation is a rare congenital disease which can produce symptoms of varying severity depending on the size of the malformation. CCT angiography can help in non-invasively diagnosing the malformation along with revealing the anatomic details, which can be used for surgical planning, or for better medical management of the patients.

Imaging of coronary artery anomalies: the role of multidetector computed tomography

BACKGROUND

Coronary artery anomalies are evaluated by using catheter-based angiography. Multidetector row-computed tomography (MDCT) is a new noninvasive imaging technique that has excellent spatial resolution for detecting the origin and course of a coronary anomalous vessel.

OBJECTIVE

To determine the sensitivity of multidetector computed tomography in patients who had coronary artery anomaly demonstrated by conventional coronary angiography.

MATERIAL AND METHODS

A retrospective evaluation to identify 23 patients, who underwent retrospective electrocardiographic (ECG)-gated MDCT, was done and in whom an anomalous coronary vessel was found at a single center. Metoprolol (50-100 mg) was given orally to all patients to reduce heart rate so as to get high-quality MDCT images. After performing MDCT, the CT scans of each patient were analysed and compared with their coronary angiograms by two experienced radiologists and one cardiologist who were unaware about the study, and the sensitivity of MDCT was determined.

RESULTS

Twenty-three patients (age range 28-73) with seven different coronary arteries of the anomalous type were evaluated. Nineteen patients had an anomalous left coronary artery; three patients had an anomalous single coronary artery; and one patient had an anomalous right coronary artery. The most common anomaly type was the left circumflex coronary artery (52%). The origin and course of all anomalous vessels were detected by ECG-gated MDCT (Lightspeed 16, GE Medical Systems, Milwaukee, Wisconsin, USA). The sensitivity of 100% of MDCT was detected in patients who had anomalous coronary vessels.

CONCLUSION

We suggest that MDCT could be a non-invasive alternative imaging technique to conventional coronary angiography for screening the anomalous vessels of coronary arteries because of its excellent spatial resolution, which is very important for detecting the relationship of anomalous vessels with great arteries and cardiac structures.

Prevalence of anatomical variants and coronary anomalies in 543 consecutive patients studied with 64-slice CT coronary angiography

The aim of our study was to assess the prevalence of variants and anomalies of the coronary artery tree in patients who underwent 64-slice computed tomography coronary angiography (CT-CA) for suspected or known coronary artery disease. A total of 543 patients (389 male, mean age 60.5 ± 10.9) were reviewed for coronary artery variants and anomalies including post-processing tools. The majority of segments were identified according to the American Heart Association scheme. The coronary dominance pattern results were: right, 86.6%; left, 9.2%; balanced, 4.2%. The left main coronary artery had a mean length of 112 ± 55 mm. The intermediate branch was present in the 21.9%. A variable number of diagonals (one, 25%; two, 49.7%; more than two, 24%; none, 1.3%) and marginals (one, 35.2%; two, 46.2%; more than two, 18%; none, 0.6%) was visualized. Furthermore, CT-CA may visualize smaller branches such as the conus branch artery (98%), the sinus node artery (91.6%), and the septal branches (93%). Single or associated coronary anomalies occurred in 18.4% of the patients, with the following distribution: 43 anomalies of origin and course, 68 intrinsic anomalies (59 myocardial bridging, nine aneurisms), three fistulas. In conclusion, 64-slice CT-CA provides optimal visualization of the variable and complex anatomy of coronary arteries because of the improved isotropic spatial resolution and flexible post-processing tool.

Demonstration of coronary arteries and major cardiac vascular structures in congenital heart disease by cardiac multidetector computed tomography angiography

BACKGROUND

Detection of coronary artery is important when considering surgical treatment of a congenital heart disease (CHD) such as tetralogy of Fallot (TF). Cardiac catheterization plays an important supplementary role in the evaluation of patients with CHD. In a few reports, it has been proposed that multidetector computed tomography (MDCT) can be helpful for the visualization of coronary arteries. We sought to demonstrate the feasibility and usefulness of MDCT angiography for anatomical evaluation of coronary arteries in CHD patients with suspected coronary artery anomalies.

MATERIALS AND METHODS

A total of 10 patients, 9 pediatric and 1 adult, underwent MDCT angiography for the investigation of coronary artery anomalies and mediastinal vascular structures. Seven patients had TF; 5 of these patients were suspected of having coronary artery anomalies and 2 were suspected of having pulmonary artery atresia or a nonconfluent pulmonary artery. The other 3 patients had truncus arteriosus and severe left pulmonary artery stenosis (n = 1), double outlet right ventricle (n = 1), and Kawasaki disease (n = 1) with suspected coronary artery aneurysms. The entire heart, major vascular structures, and coronary artery anomalies were preoperatively scanned in patients with cyanotic heart disease. Examinations were performed by 16-MDCT with 1-mm slice thickness. A breath-holding test was performed in 5 patients. Nonionic iodinated contrast material (2 cc/kg) was administered by a power injector.

RESULTS

Major vascular structures and the proximal part of the right and left coronary arteries were visualized successfully in all patients. Mid and/or distal segments of the coronary arteries were visualized in 5 patients with TF. Pulmonary vascular bed findings were also confirmed during surgery in patients with TF and in one patient with truncus arteriosus type I and severe left pulmonary artery stenosis. Kawasaki disease was diagnosed by the presence of aneurysms in one patient. Pulmonary artery atresia was confirmed in one patient and diameter of the pulmonary arteries (4 mm and 4.5 mm) was determined in the other 2 patients by MDCT.

CONCLUSION

The advantage of MDCT for cardiac imaging is the shortened scanning time for imaging the entire heart without long breath-holding times. Selective conventional coronary angiography is invasive and technically difficult in pediatric patients. We suggest that MDCT angiography can be performed as a noninvasive method in patients with CHD for the evaluation of coronary artery anatomy and anomalies and mediastinal vascular structures.

Echocardiographic Diagnosis of a Right Coronary Artery-Coronary Sinus Fistula

In this case report, we describe a 67-year-old woman with right coronary artery-coronary sinus fistula. This woman had complaints of chest pain. Ischemic ECG changes and a ventricular tachycardia were detected on her electrocardiogram. Transthoracic echocardiography showed a large right coronary artery and a dilated coronary sinus. Drainage of the coronary artery to the coronary sinus was detected by colour flow mapping during transesophageal echocardiographic examination, and a 94 mmHg peak gradient was recorded by continuous wave Doppler at the drainage site. These findings were confirmed by cardiac catheterization. Transthoracic and transesophageal echocardiography can provide definitive confirmation of the right coronary artery-coronary sinus fistula, and can be the diagnostic procedure of choice when this anomaly is suspected.

Detection and assessment of coronary artery anomalies by three-dimensional magnetic resonance coronary angiography

BACKGROUND

Coronary artery anomalies (CAAs) are a relatively rare condition usually diagnosed in vivo by conventional angiography. In the past few years Magnetic resonance coronary angiography (MRCA) has been used to detect CAAs and found to be highly accurate. No data is available regarding the ability of MRCA to detect previously not suspected anomalies.

METHODS

We prospectively analyzed the origin and course of 336 patients undergoing a diagnostic Cardiovascular magnetic resonance (CMR) study. After the completion of a standard examination a navigator-echo 3D-MRCA low-quality scan was used in all the cases to rule out CAAs. The high-quality MRCA was applied only if an abnormal coronary arterial tree was seen.

RESULTS

Nineteen patients with CAAs (12 men, 7 women; mean age, 53+/-18 years) were identified by MRCA. Six out of the 19 CAAs subjects had already been detected by other means (coronary angiography in 5, and transesophageal echocardiography in 1 case). However in none of them a complete anatomical assessment was achieved. In 13 patients CAAs were an unexpected and new finding. MRCA was able to assess the origin and proximal course of the anomalous artery in all the cases.

CONCLUSIONS

MRCA is able to detect the presence and anomalous course of CAAs. Besides offering precise information about already suspected CAAs, MRCA can identify anomalies previously not suspected. This study suggests a potential role for MRCA as a screening tool for CAAs in young patients with angina, ventricular arrhythmias, or unexplained syncope as well as in highly competitive athletes.

Anomalous origin of the left main coronary artery from the right sinus of Valsalva with an intramural course identified by transesophageal echocardiography in a 14 year old with acute myocardial infarction

Coronary artery anomalies have an incidence of 0.6% to 1.3% in angiographic studies and 0.3% in an autopsy series. Anomalous origin of the left main coronary artery (LMCA) from the right sinus of Valsalva (RSOV) represents a small fraction (1.3%) of these anomalies, with an overall prevalence of 0.017% to 0.03% in angiographic studies. The high incidence of sudden cardiac death associated with this specific anomaly during or immediately after vigorous physical exercise makes identification and appropriate surgical intervention critical. We present a case report of a 14-year-old patient with an LMCA arising from the RSOV with an initial intramural course, presenting with acute myocardial infarction (AMI) as the first indication of the anomaly. Transthoracic echocardiogram suggested this anomaly, which was confirmed by cardiac catheterization and transesophageal echocardiogram.

A Coronary Artery Fistula With Saccular Aneurysm Mimicking a Right Atrial Cystic Mass

A 16 year-old Korean girl with cardiomegaly was found to have a "right atrial cystic mass" on transthoracic echocardiography. An unusual cystic structure made the diagnosis difficult. However, transesophageal echocardiography and multidetector computed tomography revealed a coronary artery fistula with a distal saccular aneurysm involving the interatrial septum and draining into the right atrium. Multidetector computed tomography provided clear anatomic visualization that fully delineated the abnormal structures. Multidetector computed tomography may be considered as a good alternative for transesophageal echocardiography in assessing a tortuous coronary artery fistula and aneurysm with complex anatomy.

Two-dimensional and Doppler transesophageal echocardiographic delineation and flow characterization of anomalous coronary arteries in adults

OBJECTIVES

The purpose of this study was to examine the use of transesophageal echocardiography (TEE) in the identification and flow characterization of congenital coronary anomalies.

BACKGROUND

Congenital coronary anomalies in adults are rare but may cause serious cardiac complications. The use of TEE in evaluation of this entity has not been well defined. Very little is known regarding flow patterns in anomalous coronaries assessed by Doppler TEE.

METHODS

A total of 32 consecutive adult patients were studied using TEE to define the origin, course, and proximal flow pattern of suspected coronary anomalies.

RESULTS

Coronary anomalies identified using TEE included anomalous origin from the pulmonary trunk (n = 2), right sinus (n = 18), left sinus (n = 9), single coronary (n = 2), and left main coronary fistula (n = 1). Multiplane TEE performed in 20 cases simplified the delineation of more complex coronary anomalies. The origin was identified in all patients, proximal course delineated in 31, and proximal flow pattern characterized by pulsed Doppler in 23 of 32 patients. In 16 anomalous left main, left anterior descending, or left circumflex coronary arteries, an abnormal systolic flow pattern (ie, systolic/diastolic time-velocity integral ratio >1) occurred exclusively (P <.001) when the anomalous artery had an intermediate (100%; 5/5) versus anterior or posterior course (0%; 0/11) relative to the aortic and pulmonary artery trunks. A systolic flow pattern was also evident in 4 (80%) of 5 patients with an anomalous right coronary artery with an intermediate course.

CONCLUSIONS

TEE, particularly with a multiplane probe, has an important complementary role to coronary angiography in delineating the proximal course and pattern of flow in anomalous coronaries. Predominant systolic flow pattern in anatomically left proximal anomalous coronaries signifies an intermediate course between the aorta and the pulmonary trunk and may be clinically useful for risk stratification.

Assessment of congenital coronary artery fistulas by transesophageal color Doppler echocardiography

PURPOSE

Coronary angiography is the gold standard for imaging the coronary tree, but the relation of coronary artery fistulas to other structures, and their origin and course, may not be apparent. We evaluated the ability of multiplane color Doppler transesophageal echocardiography to identify coronary fistulas.

PATIENTS AND METHODS

Twenty-one patients with angiographically confirmed coronary artery fistulas were investigated by transesophageal echocardiography in four Italian hospitals between January 1997 and May 2001.

RESULTS

Transesophageal echocardiography correctly diagnosed fistulous connection in all 21 patients. This included 6 patients with connections from the left circumflex artery (into the right chambers of the heart in 5 patients, and into the left ventricle in 1 patient), 10 patients with a fistula arising from the left anterior descending artery or left main coronary artery (with drainage into the right ventricle or main pulmonary artery), and 5 patients with a fistula from the right coronary artery (with drainage sites in the lateral aspect of the right ventricle, the low posterior right atrium, or the superior vena cava). In 4 of the 21 patients, angiography did not identify the precise site of a fistula into the coronary sinus or right ventricle.

CONCLUSION

Color Doppler transesophageal echocardiography is useful in the diagnosis and in the precise localization of coronary artery fistulas.

Coronary artery fistulas

The aetiology of congenital coronary artery fistulas remains a challenging issue. Coronary arteries with an anatomically normal origin may, for obscure reasons, terminate abnormally and communicate with different single or multiple cardiac chambers or great vessels. When this occurs, the angiographic morphological appearance may vary greatly from discrete channels to plexiform network of vessels. Coronary arteriovenous fistulas (CAVFs) have neither specific signs nor pathognomonic symptoms; the spectrum of clinical features varies considerably. The clinical presentation of symptomatic cases can include angina pectoris, myocardial infarction, fatigue, dyspnoea, CHF, SBE, ventricular and supraventricular tachyarrhythmias or even sudden cardiac death. CAVFs may, however, be a coincidental finding during diagnostic coronary angiography (CAG). CAG is considered the gold standard for diagnosing and delineating the morphological anatomy and pathway of CAVFs. There are various tailored therapeutic modalities for the wide spectrum of clinical manifestations of CAVFs, including conservative pharmacological strategy, percutaneous transluminal embolisation and surgical ligation.

Visualization of coronary artery anomalies and their anatomic course by contrast-enhanced electron beam tomography and three-dimensional reconstruction

Anomalous coronary arteries are rare conditions. However, they may cause myocardial ischemia and sudden death and their reliable identification is crucial for any imaging method that attempts coronary artery visualization. We studied the ability of contrast-enhanced electron beam tomography (EBT) to identify anomalous coronary arteries and their course. Thirty patients with previously identified coronary anomalies and 30 subjects with normal coronary anatomy were studied. By EBT, 40 to 50 axial images of the heart (3-mm slice thickness, 1 mm overlap, electrocardiographic trigger) were acquired in a single breathhold during continuous injection of contrast agent (160 ml, 4 ml/s). Based on the original images and 3-dimensional reconstructions, the EBT data were analyzed by 2 blinded observers as to the presence of coronary anomalies and their course. Results were compared with invasive angiography. EBT correctly identified all normal controls and all patients with coronary anomalies. The anatomic course of the coronary anomalies was correctly classified in 29 of 30 patients (97%), including right-sided origin of the left main coronary artery (n = 4) or of the left circumflex coronary artery (n = 15), left-sided origin of the right coronary artery (n = 9), and 1 coronary fistula from the left circumflex coronary artery to the right atrium. Only the distal anastomosis of a second fistula from the left circumflex coronary artery to a bronchial artery was not correctly identified. This study demonstrates that contrast-enhanced EBT is a reliable noninvasive technique to identify anomalous coronary arteries and their course.

Left circumflex coronary artery-to-left atrium fistulas detected by transesophageal echocardiography in heart transplant recipients

Coronary fistulas are uncommon after heart transplantation. We report two cases of fistulas from an atrial branch of the circumflex coronary artery to the left atrium after heart transplantation. This has not been previously reported in the literature. They were detected with transesophageal echocardiography, and images are shown for the first time. Transesophageal echocardiography may be useful in the follow-up of heart transplant recipients.

An unusual case of bilateral coronary artery fistulas--a case report

The authors report an unusual case with bilateral coronary artery fistulas at the origin of the coronary cusps. The diagnostic technique and management are discussed.

Transcatheter embolization of congenital coronary arterial fistulas in adults

In this report, we describe our experience with transcatheter occlusion of congenital coronary arterial fistulas in adults. From November 1992 to November 1996, 5 symptomatic patients, aged from 47 to 70 years, underwent transcatheter occlusion of fistulas using a retrograde arterial approach. All had chest pain or dyspnea on exertion. Detachable balloons were used in 4 patients, and Gianturco coils in 1. Detachable balloons were implanted through a Debrun system, while the coils were implanted through a 5 French right coronary Judkins catheter. Both were passed through an 8 French guiding catheter (Amplatz II). Each patient had a single fistula. The fistulas originated from the right coronary artery in 3 patients, and from the circumflex artery in 2. They drained into the pulmonary trunk in 3 patients, into the right atrium in 1, and into a bronchial artery in the other. All fistulas were occluded completely in the catheterization laboratory, and the procedures were uncomplicated. At follow up, 3 patients underwent coronary angiography, and there was no evidence of recanalization. Transcatheter embolization in adults of single congenital coronary fistulas with detachable balloons and coils is safe and effective and can be regarded as an acceptable alternative to surgery.

Anomalous origin of coronary arteries and risk of sudden death: a study based on an autopsy population of congenital heart disease

Coronary arteries anomalies may be part of complex congenital malformations of the heart or be an isolated defect. In our anatomic collection of congenital heart disease, an isolated anomalous origin of coronary arteries was observed in 27 of 1,200 specimens (2.2%): left coronary artery from pulmonary trunk in five, origin from the wrong aortic sinus in 12 (both right and left coronary artery from the right sinus in four and from the left sinus in seven, left coronary artery from the posterior sinus in one), left circumflex branch from right aortic sinus or from very proximal right coronary artery in three, high takeoff of right coronary artery in three, stenosis of the coronary ostia attributable to valvelike ridge in four. In 16 (59%) patients (12 males and 4 females, age ranging from 2 months to 53 years; median, 14), the final outcome was sudden death; it occurred in all cases of left coronary artery origin from right aortic sinus, in 43% of right coronary artery origin from left aortic sinus, and in 40% of the left coronary artery from the pulmonary trunk. Sudden death was precipitated by effort in eight (50%) and was the first manifestation of the disease in eight (50%); previous symptoms consisted of recurrent syncope in four, palpitations in three, and chest pain in one. Five patients who died suddenly during effort were athletes. In conclusion, (1) more than half of our postmortem cases with anomalous origin of coronary arteries died suddenly, (2) all but two patients with sudden death had anomalous coronary artery origin from the aorta itself, (3) the fatal event was frequently precipitated by effort, (4) palpitations, syncope, and ventricular arrhythmias were the only prodromic symptoms and signs. Recognition during life of these coronary anomalies, by the use of noninvasive procedures, is mandatory to prevent the risk of sudden death and to plan surgical correction if clinically indicated.

Multiplane transesophageal echocardiography in diagnosis of 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 in adults is difficult to identify reliably by transthoracic echocardiography (TTE). We describe a 32-year-old woman with this coronary anomaly mimicking a coronary artery fistula on conventional TTE study. This anomaly was suggested by multiplane transesophageal echocardiography (TEE) and subsequently confirmed by coronary angiography. Multiplane TEE thus may serve as a first-line diagnostic tool for detecting anomalous origin of coronary arteries.

Non-invasive diagnosis of a congenital coronary artery fistula

This report describes a large congenital coronary artery fistula of the left circumflex artery draining into the coronary sinus in a 46 year old woman. The fistula was initially diagnosed by cross-sectional and transesopha-geal echocardiography using multiplane probe. Additionally, the entire course of the fistula was visualised in electron beam tomography. Angiography confirmed echocardiographic and tomographic findings.

Coronary anomalies diagnosed with transesophageal echocardiography: complementary clinical value in adults

INTRODUCTION

Coronary arteriography remains a gold standard for the evaluation of coronary anatomy. In the case of anatomical anomalies, understanding of vessel course based upon a coronary angiogram may be difficult. Transesophageal echocardiography is a noninvasive method allowing tomographic visualization of proximal coronary arteries. Experience concerning its usefulness for the assessment of anomalous coronary arteries is limited.

MATERIAL

Eleven patients with confirmed coronary anomalies studied between 1993-96 were identified in the cohort of those undergoing transesophageal echocardiography.

RESULTS

Transesophageal echocardiography revealed potentially serious anomalies (origin of left or right coronary artery from contralateral aortic sinus) in 3 patients and benign in 8. Coronary ostia and proximal course could be delineated in all patients. Anatomical information was consistent between methods, except for a separate origin of the left anterior descending and circumflex artery, where the angiogram missed a very short common left main coronary artery in 2 patients. The relationship between the coronary arteries, aorta and pulmonary trunk was better defined by the echocardiogram. Doppler flow analysis allowed us to exclude anomaly-related flow disturbances.

CONCLUSIONS

Transesophageal echocardiography can be considered as a noninvasive technique with the potential for anatomical and functional evaluation of anomalous proximal coronary arteries and deserves a routine use whenever such a condition is suspected. This approach may simplify invasive procedures in this patient group.

Magnetic resonance imaging in diagnosis of right coronary arteriovenous fistula--a case report

We describe a patient with a right coronary arteriovenous fistula in whom magnetic resonance imaging (MRI) was useful in establishing the diagnosis. In a 36-year-old woman, T1 spin echo MRI demonstrated a massively dilated coronary arteriovenous fistula connecting the right coronary artery to the right atrium. The cine field echo technique showed a continuous shunt flow within the fistula as documented by the flow void throughout the cardiac cycle. These findings were confirmed by cardiac catheterization. We conclude that MRI is useful not only in detecting a coronary arteriovenous fistula but also in identifying its origin and the drainage site.

Anomalous right or left coronary artery from the contralateral coronary sinus: "high-risk" abnormalities in the initial coronary artery course and heterogeneous clinical outcomes

Coronary artery anomalies are associated with sudden cardiac death, although individual patient outcomes are highly variable. We performed blinded pathologic analysis of 30 consecutive cases of anomalous right (n = 21) or left (n = 9) coronary artery from the contralateral coronary sinus to determine which, if any, features might aid in risk stratification for sudden cardiac death. We found no significant differences in length of aortic intramural segment, coronary ostial size, degree of displacement of the anomalous coronary artery from the correct coronary sinus, or angle of coronary takeoff between patients with (n = 12) and without (n = 18) sudden cardiac death. All pathologic features showed considerable interpatient variability. Age > or = 30 years was the only variable associated with a decreased incidence of sudden cardiac death. Thus no simple relation exists between variations in the initial coronary artery course and clinical outcome in these anomalies.

Value of transoesophageal echocardiography in surgical ligation of coronary artery fistulas

Images

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.

Multiplane transesophageal echocardiography in the diagnosis of congenital coronary artery fistula

The purpose of this study was to examine the advantages of multiplane transesophageal echocardiography in the diagnosis of congenital coronary artery fistula, specifically in depicting the origin, the course, and the drainage site. Seven consecutive patients ranging in age from 20 to 72 years with a suspected coronary artery fistula underwent conventional transthoracic and multiplane transesophageal echocardiographic studies between March 1993 and July 1994. When a coronary artery fistula was noted, the origin, the course, and the drainage site were carefully searched for. All patients then underwent a cardiac catheterization with the performance of coronary angiography. A large right coronary artery fistula was detected in three patients; one of them had a drainage to the posterior left ventricle, one to the lateral right ventricle, and the other to the medial aspect of the right ventricle just below the insertion of the septal leaflet of the tricuspid valve. A small coronary artery fistula arising from the left coronary artery was noted in four patients, two from the left anterior descending artery and the other two from the left circumflex artery. Three of these four patients had a drainage to the main pulmonary artery and one to the left ventricle. The drainage site was clearly depicted in all seven patients, whereas the origin and the course were precisely defined in five patients by using multiplane transesophageal echocardiographic examination. The multiplane transesophageal echocardiography provides a panoramic view of the coronary artery and the fistulous vessel with a precise definition of the origin, the course, and the drainage site of the fistula. Therefore it is the noninvasive diagnostic mode of choice.