Transthoracic echocardiography for imaging of the different coronary artery segments: a feasibility study

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

Abstract

Background: Transthoracic echocardiography (TTE) may be used for direct inspection of various parts of the main coronary arteries for detection of coronary stenoses and occlusions. We aimed to assess the feasibility of TTE to visualise the complete segments of the left main (LM), left descending (LAD), circumflex (Cx) and right (RCA) coronary arteries.

Methods: One hundred and eleven patients scheduled for diagnostic coronary angiography because of chest pain or acute coronary syndrome had a TTE study to map the passage of the main coronary arteries. LAD, Cx and RCA were each divided into proximal, middle and distal segments. If any part of the individual segment of a coronary artery with antegrade blood flow was not visualised, the segment was labeled as not satisfactorily seen.

Results: Complete imaging of the LM was achieved in 98% of the patients. With antegrade directed coronary artery flow, the proximal, middle and distal segments of LAD were completely seen in 96%, 95% and 91% of patients, respectively. Adding the completely seen segments with antegrade coronary flow and segments with retrograde coronary flow, the proximal, middle and distal segments of LAD were adequately visualised in 96%, 96% and 93% of patients, respectively. With antegrade directed coronary artery flow, the proximal, middle and distal segments of Cx were completely seen in 88%, 61% and 3% and in RCA in 40%, 28% and 54% of patients. Retrograde coronary artery flow was correctly identified as verified by coronary angiography in seven coronary segments, mainly in the posterior descending artery (labeled as the distal segment of RCA) and distal LAD.

Conclusions: TTE is a feasible method for complete demonstration of coronary flow in the LM, the proximal Cx and the different segments of LAD, but less suitable for the RCA and mid and distal segments of the Cx. (ClinicalTrials.gov number NTC00281346.).

Trial registration: ClinicalTrials.gov NCT00281346.

Figures

Figure 1
Figure 1
Examples of antegrade coronary artery flow in the LM and proximal parts of LAD. (A) In modified parasternal short-axis view the left main coronary artery (LM) is seen leaving the left sinus of Valsalva and continuing as the left anterior descending coronary artery (LAD) turning slightly towards the transducer. (B) In modified parasternal short-axis view the first septal branch (SB) is seen leaving the LAD. Ao = aortic root; LA = left atrium; LAA = left atrial appendage; PA = pulmonary artery.
Figure 2
Figure 2
Examples of antegrade coronary artery flow in the middle and distal segments of LAD. (A) The middle left anterior descending coronary artery (mLAD) is imaged from parasternal modified long-axis view focusing on the anterior interventricular sulcus. (B) The distal left anterior descending coronary artery (dLAD) is seen from modified apical 3-chamber view focusing on the anterior interventricular sulcus. Ax = apex of the left ventricle; LAVR = left atrioventricular ring; LV = left ventricle; MV = mitral valve; RV = right ventricle.
Figure 3
Figure 3
Examples of antegrade coronary artery flow in the proximal and middle segments of Cx. (A) In modified parasternal short-axis view focusing on the area adjacent to the left sinus of Valsalva the proximal circumflex coronary artery (pCx) is seen leaving the left main coronary artery (LM). (B and C) In modified parasternal short-axis views the proximal and middle segments of the circumflex coronary artery (Cx) are found passing caudally in the lateral atrioventricular sulcus. (D) From parasternal modified long-axis view focusing on the lateral atrioventricular sulcus the middle Cx (mCx) is seen traversing caudally. Ao = aortic root/valve; LA = left atrium; LAD = left anterior descending coronary artery; LV = left ventricle; mLAD = middle segment of LAD; PA = pulmonary artery; pLAD = proximal segment of LAD; RV = right ventricle.
Figure 4
Figure 4
Example of antegrade coronary artery flow in the distal segment of Cx. The distal segment of the circumflex coronary artery (dCx) imaged by colour Doppler mapping and matching spectral Doppler tracings of blood flow (with arrowheads denoting diastolic flow waveform with one diastolic flow velocity waveform enveloped), imaged from modified subcostal short-axis view focusing on the inferior atrioventricular sulcus. L = liver; LV = left ventricle; RV = right ventricle.
Figure 5
Figure 5
Examples of antegrade coronary artery flow in the RCA and PDA. (A) In modified parasternal short-axis view searching the area adjacent to the right sinus of Valsalva the proximal right coronary artery (pRCA) is seen leaving the aortic root (Ao). (B) From subcostal modified sagittal view the pRCA is seen traversing caudally on the anterior tricuspid ring. (C) Using subcostal modified short-axis view parts of the middle segment of the right coronary artery (mRCA) are seen coursing medially on the medial tricuspid ring. (D) From modified apical 2-chamber view focusing on the posterior interventricular sulcus parts of the posterior descending coronary artery (PDA) are seen coursing toward the apex (Ax). L = liver; LA = left atrium; LV = left ventricle; RA = right atrium; RV = right ventricle.
Figure 6
Figure 6
Examples of antegrade and retrograde flow in the middle segment of LAD. The middle segment of the left anterior descending coronary artery (mLAD) imaged by colour Doppler mapping and matching spectral Doppler tracings of blood flow, imaged from modified parasternal short-axis view focusing on the anterior interventricular sulcus: (A) The mLAD is seen with antegrade flow. (B) The mLAD is seen with retrograde flow. D = spectral Doppler tracings of diastolic coronary blood flow; IVS = interventricular septum; LV = left ventricle; RV = right ventricle; S = spectral Doppler tracings of systolic coronary blood flow.

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