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

OBJECTIVE

To examine the role of transoesophageal echocardiography in the assessment of patients with coronary artery anomalies.

BACKGROUND

Coronary artery anomalies are difficult to detect clinically. Most are benign but some may produce symptoms that can be life threatening. Until recently the non-invasive assessment of coronary artery anomalies has been limited.

METHODS

The data base of transoesophageal echocardiographic studies performed between September 1988 and April 1991 were reviewed to identify all cases of coronary artery anomalies. There were six patients with such anomalies who had also had coronary angiography. The findings of these two imaging techniques were analysed to determine whether transoesophageal echocardiography added useful data in these cases.

RESULTS

Of the six patients, the coronary anomaly was discovered during angiography in four patients, during a transthoracic echocardiographic study in one patient, and as an incidental finding in the other patient. Aberrant origins of the left coronary artery were detected in two patients, and coronary artery fistulae were present in the other four. Transoesophageal echocardiography provided unique information on the course of an aberrant left coronary artery in one patient and the precise location of drainage sites of coronary artery fistulas in three patients.

CONCLUSION

Transoesophageal echocardiography was complementary to angiography in the assessment of coronary artery anomalies. It can locate and delineate the course of an ectopic coronary artery and the drainage site of a coronary fistula. These anatomical data can be crucial to the management of these patients.

Left atrial mass produced by extensive mitral annular calcification

An unusual case of mitral annular calcification presenting as a left atrial mass is discussed. The differential diagnosis of left atrial masses with particular reference to their echocardiographic features is reviewed.

Echocardiographic detection of pulmonary emboli-in-transit

Echocardiography can detect pulmonary emboli-in-transit as mobile masses within the right heart. In this case report, a patient with biventricular failure had both transthoracic and transesophageal echocardiograms which revealed a thromboembolus entrapped within the right atrium. Surgery confirmed the echocardiographic findings.

Fatal angioedema associated with enalapril

A 65-year-old male with a long history of congestive heart failure presented to the emergency room with facial swelling 7 h after the first dose of enalapril. He was treated with diphenhydramine and hydrocortisone which improved his angioedema. However, there was a profound relapse of the angioedema followed by respiratory arrest. He suffered severe anoxic brain damage and died five days later. It is likely that the long half-life of enalapril lead to this rebound phenomenon. Enalapril induced angioedema is reviewed with suggestions for management.