Coronary artery occlusions diagnosed by transthoracic Doppler

Johnny Vegsundvåg, Espen Holte, Rune Wiseth, Knut Hegbom, Torstein Hole, Johnny Vegsundvåg, Espen Holte, Rune Wiseth, Knut Hegbom, Torstein Hole

Abstract

Background: Our aim was to assess whether anterograde flow velocities in septal perforating branches could identify an occluded contralateral coronary artery, and to assess the feasibility and accuracy of diagnosing occlusions in the three main coronary arteries by the combined use of several noninvasive parameters indicating collateral flow.

Methods: A total of 108 patients scheduled for coronary angiography because of chest pain or acute coronary syndromes were studied using transthoracic Doppler echocardiography.

Results: Anterograde peak diastolic flow velocities (pDV) in septal perforating branches were higher in patients with angiographic occluded contralateral artery compared with corresponding velocities in patients without significant disease in the contralateral artery (0.80 ± 0.31 m/sec versus 0.37 ± 0.13 m/sec, p < 0.001). Receiver operating characteristic curve showed pDV ≥ 0.57 m/sec to be the optimal cutoff value to identify occluded contralateral artery, with a sensitivity of 79% and a specificity of 69%. Demonstration of at least one positive parameter (retrograde flow in main coronary arteries, reversed flow in septal perforating and left circumflex marginal branches, pDV ≥ 0.57 m/sec, or demonstration of other epicardial or intramyocardial collaterals) indicating collateral flow to an occluded main coronary artery had sensitivity, specificity, positive and negative predictive value of 89%, 94%, 63%, and 99%, respectively, for detection of a coronary occlusion. With this combined use of several parameters, 25 of 28 coronary occlusions were identified.

Conclusions: By investigating several parameters indicating collateral flow, we were able to identify most of the main coronary occlusions in the patient cohort. Furthermore, our study demonstrated that coronary artery occlusions may result in complex and diverging coronary pathophysiology depending on which coronary artery segment is occluded and the extent of accompanying coronary artery disease.

Trial registration: ClinicalTrials.gov number NTC00281346.

Trial registration: ClinicalTrials.gov NCT00281346.

Figures

Figure 1
Figure 1
Examples of anterograde and retrograde flow in the posterior descending coronary artery. In modified apical long-axis views focusing on the posterior interventricular sulcus, the posterior descending coronary artery (PDA) is imaged by colour Doppler mapping with matching spectral Doppler tracings of blood flow: (A,B) The PDA is seen with anterograde flow. (C,D) The PDA is seen with retrograde flow. Ao = aortic valve and ascending aorta, Ax = apex, D = spectral Doppler tracings of diastolic coronary blood flow, LA = left atrium, LV = left ventricle, RA = right atrium, S = spectral Doppler tracings of systolic coronary blood flow.
Figure 2
Figure 2
Examples of anterograde and retrograde flow in marginal branches of the left circumflex coronary artery. In modified apical four chamber views, a marginal branch of the left circumflex coronary artery (CxMb) is imaged by colour Doppler mapping with matching spectral Doppler tracings of blood flow: (A,B) The CxMb is seen with anterograde flow. (C,D) The CxMb is seen with retrograde flow. Ao = aortic valve and ascending aorta, D = spectral Doppler tracings of diastolic coronary blood flow, IS = interventricular septum, LA = left atrium, LV = left ventricle, MR = mitral ring, RA = right atrium, RV = right ventricle, S = spectral Doppler tracings of systolic coronary blood flow.
Figure 3
Figure 3
Examples of normal anterograde and abnormal retrograde blood flow in septal perforating branches. (A) In a modified parasternal short-axis view, a septal perforating branch from the left anterior descending coronary artery (Sb-LAD) is seen with anterograde blood flow. (B) In a modified parasternal short-axis view, a septal perforating branch from the posterior descending coronary artery (Sb-PDA) is seen with anterograde blood flow. (C) Spectral Doppler tracings of the anterograde blood flood in a Sb-LAD. (D) In a modified parasternal short-axis view, a Sb-PDA is seen with retrograde blood flow. AW = anterior wall of the left ventricle, D = spectral Doppler tracings of diastolic coronary blood flow, IS = interventricular septum, IW = inferior wall of the left ventricle, LV = left ventricle, mLAD = parts of the middle segment of the left anterior descending coronary artery, RV = right ventricle.
Figure 4
Figure 4
Example of a transthoracic Doppler finding of retrograde collateral blood flow in a septal perforating branch, compared with coronary angiography. (A) In a modified parasternal short-axis view, a septal perforating branch from the left anterior descending coronary artery (Sb-LAD) is seen with retrograde blood flow. (B) Angiogram of the right coronary artery (RCA) demonstrates collateral (CL) blood supply from the posterior descending coronary artery (PDA) through the septal perforating branches to the left anterior descending coronary artery (LAD). Angiogram of the left coronary artery demonstrated proximal LAD occlusion (not shown). AW = anterior wall of the left ventricle, IS = interventricular septum, IW = inferior wall of the left ventricle, LV = left ventricle, RV = right ventricle.
Figure 5
Figure 5
Example of transthoracic Doppler findings of collateral blood flow in the apical region, compared with coronary angiography. (A) In a modified parasternal long-axis view focusing on the apex and distal anterior interventricular sulcus, several epicardial and intramyocardial collaterals (CL) originates from the distal left anterior descending coronary artery (dLAD). (B) Angiogram of the left coronary artery demonstrates apically located epicardial and intramyocardial collateral (CL) blood supply from the dLAD to the posterior descending coronary artery (PDA), which shows retrograde flow. Angiogram of the right coronary artery demonstrated a proximal PDA occlusion (not shown). LAD = left anterior descending coronary artery, LV = left ventricle, RV = right ventricle.
Figure 6
Figure 6
ROC curve for anterograde peak diastolic flow velocities in septal perforators in diagnosing contralateral coronary occlusion. Receiver operating characteristic (ROC) curve for anterograde peak diastolic flow velocities (pDV) in septal perforating branches in the diagnosis of occlusion in the contralateral, collateral-receiving main coronary artery, with optimal pDV ≥ 0.57 m/sec (sensitivity 79%, specificity 69%). AUC = area under the curve, CI = confidence interval, DS = diameter stenosis.

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