Year : 2014  |  Volume : 7  |  Issue : 3  |  Page : 230--232

Anomalous origin of left coronary artery from pulmonary artery - Duped by 2D; saved by color Doppler: Echocardiographic lesson from two cases


Tharakanatha R Yarrabolu, Nazire Ozcelik, Jose Quinones, Matthew D Brown, Duraisamy Balaguru 
 Department of Pediatrics, Division of Pediatrics Cardiology, University of Texas at Houston Medical School and Children's Memorial Hermann Hospital, Houston, Texas, USA

Correspondence Address:
Duraisamy Balaguru
Department of Pediatrics, Division of Pediatric Cardiology, University of Texas-Houston Medical School, 6410 Fannin Street, UTPB Suite # 425, Houston, Texas 77030
USA

Abstract

Echocardiography is an important first-line investigation for detection of anomalous origin of a coronary artery from the pulmonary artery (ALCAPA). We report two cases of ALCAPA that illustrate the importance of systematic performance of the echocardiogram, mindful of technical artifacts that may mislead the echocardiographer color Doppler imaging in diagnosis of this condition.



How to cite this article:
Yarrabolu TR, Ozcelik N, Quinones J, Brown MD, Balaguru D. Anomalous origin of left coronary artery from pulmonary artery - Duped by 2D; saved by color Doppler: Echocardiographic lesson from two cases.Ann Pediatr Card 2014;7:230-232


How to cite this URL:
Yarrabolu TR, Ozcelik N, Quinones J, Brown MD, Balaguru D. Anomalous origin of left coronary artery from pulmonary artery - Duped by 2D; saved by color Doppler: Echocardiographic lesson from two cases. Ann Pediatr Card [serial online] 2014 [cited 2020 Oct 1 ];7:230-232
Available from: http://www.annalspc.com/text.asp?2014/7/3/230/140862


Full Text

 CASE REPORT



Echocardiography is the screening imaging tool for diagnosis of anomalous origin of left coronary artery from pulmonary artery (ALCAPA). We present two cases (1 year old and 10 year old, respectively) where the 2-dimensional (2D) echocardiographic images showed an apparent origin of left coronary artery (LCA) from aorta due to a drop-out artifact [Figure 1]a and [Figure 3]a]. However, color Doppler in diastole showed blue signal [Figures 1b and 3b] suggestive of flow towards the aorta. This abnormal color Doppler signal prompted angiography in both patients that confirmed the diagnosis of ALCAPA [Figure 2] and [Figure 4]. Case 1 [Figure 1] and [Figure 2] is a 1-year-old baby girl who presented as "dilated cardiomyopathy" with moderate left ventricle (LV) systolic dysfunction. Case 2 [Figures 2 and 4] is a 10-year boy who presented with chest pain on exertion and had normal LV systolic function. Both patients underwent surgical repair with good outcome. [Figure 5] illustrates the mechanism by which the apparent drop-out may occur. This tissue separation between the coronary artery and aortic lumen may be "dropped" when the tissue is parallel to the beams of ultrasound shown by dotted lines in [Figure 5]. These two cases illustrate the importance of evaluating coronary arteries both by 2D and color Doppler images.{Figure 1}{Figure 2}{Figure 3}{Figure 4}{Figure 5}

 DISCUSSION



This phenomenon has been well described in literature. [1],[2],[3],[4]

Artifactual "drop-out" at coronary origin in the 2D images as we described above - in spite of optimized probe position and gain setting on the echocardiography machine orTransverse sinus of pericardium presenting as an echo-free linear space that is mistaken for a coronary artery origin in parasternal short axis view. [2]

This misleading finding in 2D images may be overcome by repositioning the ultrasound transducer to a more angular vantage point in the chest, optimizing Doppler scale settings and awareness of transverse pericardial sinus anatomy. When the color signal is abnormal, the echocardiographer should pursue to demonstrate other indirect signs such as abnormal flow into the main pulmonary artery, dilatation of the opposite coronary artery and evidence of collateral flow.

 CONCLUSION



Coronary artery evaluation by echocardiogram should be performed systematically in all patients using both 2D and color Doppler as a routine. This will ensure acquisition of necessary skills by the echocardiographer and the physician.

References

1Robinson PJ, Sullivan ID, Kumpeng V, Anderson RH, Macartney FJ. Anomalous origin of the left coronary artery from the pulmonary trunk. Potential for false negative diagnosis with cross sectional echocardiography. Br Heart J 1984;52:272-7.
2Schmidt KG, Cooper MJ, Silverman NH, Stanger P. Pulmonary artery origin of the left coronary artery: Diagnosis by two-dimensional echocardiography, pulsed Doppler ultrasound and color flow mapping. J Am Coll Cardiol 1988;11:396-402.
3Karr, SS, Parness IA, Spevak, PJ, van der Velde ME, Colan SD, Sanders SP. Diagnosis of anomalous left coronary artery by Doppler color flow mapping: Distinction from other causes of dilated cardiomyopathy. J Am Coll Cardiol 1992;19:1271-5.
4Jiang GP, Wang HF, Gong FQ, He J, Ye JJ, Wang W. Diagnostic value of parasternal pulmonary artery short-axis view for the anomalous origin of the left coronary artery from the pulmonary artery. J Cardiol 2013.