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

Vegsundvåg J, Holte E, Wiseth R, Hegbom K, Hole T - Cardiovasc Ultrasound (2009)

Bottom Line: 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.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.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.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of Internal Medicine, Alesund Hospital, Alesund, Norway. johnnyvegsundvag@adsl.no

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.).

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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.
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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.

Mentions: With the patient in the supine, left and right lateral decubitus positions, all standard and modified apical, parasternal, and subcostal views were used to follow the course of the LM, LAD, Cx and RCA, from the start of each artery and distally as far as possible. With the patient in the left lateral decubitus position, the LM was examined from the left parasternal short- and long-axis views focusing on the area adjacent to the left sinus of Valsalva cranial to the aortic valve (Figure 1A). In the same short- and long-axis views the proximal LAD (pLAD) could be seen leaving the LM and turning slightly towards the transducer (Figure 1A). The LM and pLAD could also be imaged from modified apical 5- and 2-chamber views in many patients. Origin of the first septal branch was often identified, marking the transition from the pLAD to the middle segment of LAD (mLAD) (Figure 1B). If the first septal branch was not visualised, the division between the pLAD and mLAD was set approximately halfway to the level of the left ventricular papillary muscles. The course of the mLAD and distal LAD (dLAD) was imaged from parasternal modified short- and long-axis views focusing on the anterior interventricular sulcus, and the same arterial segments could also be seen from modified apical 2- and 3-chamber views (Figure 2). The level of the left ventricular papillary muscles marked the division between the mid and distal segments of the LAD. The origin and proximal part of the Cx (pCx) was found by using the same views as searching for the LM. By focusing on the atrioventricular sulcus, the pCx was seen passing in front of the left atrial appendage. The level of the inferor wall of the left atrial appendage marked the division between the pCx and middle segment of the Cx (mCx). By modified parasternal short-axis views, and sometimes subcostal short-axis views, mCx was visualised as it passed caudally in the atrioventricular sulcus to the inferior margin of the sulcus, and the artery continued further in the atrioventricular sulcus as the distal segment of the Cx (dCx). The different segments of Cx are imaged in Figure 3 and 4. With the patient in the right or left decubitus position using parasternal short-axis views, the proximal segment of the RCA (pRCA) was looked for in the area adjacent to the right sinus of Valsalva cranial to the aortic valve (Figure 5A). The rest of the pRCA was visualised from supine subcostal modified sagittal and 4-chamber views focusing on the anterior tricuspid ring (Figure 5B). The pRCA was considered as the part of RCA passing anterior surface of the tricuspid ring as far as the inferior margin of the right ventricle. Since we had some problems defining the transition between the middle and distal part of the RCA, these segments were labeled together as the middle segment of RCA (mRCA). This combined arterial segment was seen by focusing on the medial and posterior tricuspid ring using subcostal modified short-axis and 4-chamber views (Figure 5C). We labeled the posterior descending artery (PDA) as the distal segment of RCA, and this segment was imaged from modified apical 2-chamber views coursing toward the apex in the posterior interventricular sulcus (Figure 5D).


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

Vegsundvåg J, Holte E, Wiseth R, Hegbom K, Hole T - Cardiovasc Ultrasound (2009)

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.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC2806270&req=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.
Mentions: With the patient in the supine, left and right lateral decubitus positions, all standard and modified apical, parasternal, and subcostal views were used to follow the course of the LM, LAD, Cx and RCA, from the start of each artery and distally as far as possible. With the patient in the left lateral decubitus position, the LM was examined from the left parasternal short- and long-axis views focusing on the area adjacent to the left sinus of Valsalva cranial to the aortic valve (Figure 1A). In the same short- and long-axis views the proximal LAD (pLAD) could be seen leaving the LM and turning slightly towards the transducer (Figure 1A). The LM and pLAD could also be imaged from modified apical 5- and 2-chamber views in many patients. Origin of the first septal branch was often identified, marking the transition from the pLAD to the middle segment of LAD (mLAD) (Figure 1B). If the first septal branch was not visualised, the division between the pLAD and mLAD was set approximately halfway to the level of the left ventricular papillary muscles. The course of the mLAD and distal LAD (dLAD) was imaged from parasternal modified short- and long-axis views focusing on the anterior interventricular sulcus, and the same arterial segments could also be seen from modified apical 2- and 3-chamber views (Figure 2). The level of the left ventricular papillary muscles marked the division between the mid and distal segments of the LAD. The origin and proximal part of the Cx (pCx) was found by using the same views as searching for the LM. By focusing on the atrioventricular sulcus, the pCx was seen passing in front of the left atrial appendage. The level of the inferor wall of the left atrial appendage marked the division between the pCx and middle segment of the Cx (mCx). By modified parasternal short-axis views, and sometimes subcostal short-axis views, mCx was visualised as it passed caudally in the atrioventricular sulcus to the inferior margin of the sulcus, and the artery continued further in the atrioventricular sulcus as the distal segment of the Cx (dCx). The different segments of Cx are imaged in Figure 3 and 4. With the patient in the right or left decubitus position using parasternal short-axis views, the proximal segment of the RCA (pRCA) was looked for in the area adjacent to the right sinus of Valsalva cranial to the aortic valve (Figure 5A). The rest of the pRCA was visualised from supine subcostal modified sagittal and 4-chamber views focusing on the anterior tricuspid ring (Figure 5B). The pRCA was considered as the part of RCA passing anterior surface of the tricuspid ring as far as the inferior margin of the right ventricle. Since we had some problems defining the transition between the middle and distal part of the RCA, these segments were labeled together as the middle segment of RCA (mRCA). This combined arterial segment was seen by focusing on the medial and posterior tricuspid ring using subcostal modified short-axis and 4-chamber views (Figure 5C). We labeled the posterior descending artery (PDA) as the distal segment of RCA, and this segment was imaged from modified apical 2-chamber views coursing toward the apex in the posterior interventricular sulcus (Figure 5D).

Bottom Line: 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.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.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.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of Internal Medicine, Alesund Hospital, Alesund, Norway. johnnyvegsundvag@adsl.no

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.).

Show MeSH
Related in: MedlinePlus