Coronary Fistula vs. VSD. Difference in Doppler trace (timing of the trace)

Doppler flow peak in systole in VSD, but it peaks in diastole in coronary fistula.
 

Strain rate imaging - Peak systolic strain - Polar map

Coronary artery distribution:

Coronary Angiography - For anomalous aortic origins

All images are from The Cardiac Catheterization Handbook. by Morton J. Kern. Third edition 1999. p.311-317.

Cath: Coronary Angiographic Views

Coronary angiographic views
Left coronary artery:

LMCA - PA or RAO 5-10°

LAD/LCX bifurcation - LAO 30-35°/Cr 20-30°

LCX & Marginals - RAO 30-40°/Caudal 20-30°

LAD & Diagnonals - RAO 5-30°/Cranial 20-45°

LAD/LCX bifurcation,
LCX & Marginals - LAO 50-60°/Caudal 10-20° (Spider view)

Bypass to LAD - Lateral (Optional)

Right coronary artery:

Prox, Mid, PDA - LAO 30-45°/Cr 15-20°

Prox, Mid, PDA - RAO 30-45°

Optional - Lateral

(From p. 288. The Cardiac Catheterization Handbook. 3rd edition. Ed. Morton J. Kern. Mosby, St Louis 1999).

Angiogram: ALCAPA, but with a twist!

It is ALCAPA alright. But, look at the still frame below. There is a coronary artery originating from the aortic root as well! You will see it when you see the angiogram again. Needs more views to solve this.

Okay, this is not a standard case. Normally-arising vessel from left coronary sinus of aorta was mainly LCX with a rudimentary LAD. The one arising from PA, was supplying major part of LV. We mulled over what to do with this patient. Finally, she had a CABG to LCA from PA with ligation of origin of LCA from PA. Reimplanting this to aortic root is another option.

Anatomy: Coronary Veins ...& Coronary Arteries

ALCAPA - Importance of Color Doppler Signal & Unfortunate artifact in 2D

Following 3 images are from a 14 yr old boy complaining of exercise-related dizziness, palpitation and chest discomfort.


Figure 1: Parasternal short axis view...unfortunately has an artifactual drop out which was misleading. Here, LCA appears to be clearly originating from aorta. However, the color Doppler signal in second image raises a red-flag.




Figure 2: This image with color flow Doppler signal in LCA indicates "wrong" direction of flow in LCA. This finding lead to performance of an angiogram (Figure 3).


Figure 3: RAO view of selective left coronary angiogram showing retrograde filling of left coronary system which ultimately drains into Main Pulmonary Artery. Venous catheter is in MPA.

Retrospectively, there is a "drop-out" of the thin membranous separation between Aorta and LCA which is originating from MPA, but travel close to the wall of aorta. This emphasizes the importance of showing coronary origins both by 2D and color Doppler.

Also, such demonstration with 2D and color Doppler will eliminate possibility of mistaking transverse sinus of the pericardium around the great arteries for coronary arteries by 2D. Color Doppler will show fail to demonstrate flow in transverse sinus (folds of pericardium).

Gen: Coronary Artery Anomalies in d-TGA, TOF, l-TGA...

Normal coronary anatomy: (Figures from Braunwald)

Coronary Anomalies in TOF

(Preoperative angiography in infants with tetrad of Fallot. Review of 39 cases. Am J Cardiol. 1981 Jun;47(6):1279-85)

Coronary Anomalies in d-TGA
Figure from Mavroudis's book:

(Ref: Rossi MB, Ho SY, Anderson RH, et al. Ann Thorac Surg 1986;42:573)

Figures from Eugene Braunwald's Atlas (Vol XII):

(TGA & Coronary Patterns - Ursula Sauer & Adrianna C. Gittenberger-deGroot)

1. General rules (observations) about coronary arrangement in TGA:
Four rules:
(a) Three main epicardial branches exist: ("L" for LAD, "CX" for LCX and "R" for RCA)
(b) Coronaries connect exclusively to the aortic sinuses that face the pulmonary orifice
(c) Connections between ostia and branches tend to take the shortest course; and coronaries never cross each other
(d) Positional nomenclature of the aortic sinuses facing the pulmonary orifice cause confusion.
Therefore, the following nomenclature is proposed by Dr. Gittenberger-deGroot.

2. Common Coronary Patterns in d-TGA:

Patterns of Intramural Coronaries in TGA:

Proximal course of coronary arteries in TGA:

Coronary pattern incidence in different types of TGA:

Figure from Aldo Castaneda's book:

Common Coronary Artery arrangements in d-TGA

Anatomy of the coronary arteries in TGA and methods for their transfer in anatomic correction.

(Yacoub, MH. & Radley-Smith, R. Thorax 1978;33:418-424)

(Figure is a view from front of the patient - observer facing the patient).

Total number of patients in the report = 18

a: (n=11) "Normal for TGA" pattern. Origins are at the center of the sinus.

b: (n=2) Single left coronary (Origin is closer to a commissure than in center of the sinus). LCA travels between great arteries

c: (n=1) Coronaries originate from very close to the commissures

d: (n=3) RCA gives off LCx. LAD alone comes off the left posterior sinus

e: (n=1) LCx has separate origin from right posterior sinus; RCA and LAD have a common origin...I believe that either description or the figure has an error in "e".

Figure from Kirklin/Barratt-Boyes Cardiac Surgery:

(Quaegebeur JM. The arterial switch operation. Rationale, results and perspectives. Thesis; Leiden University, The Netherlands; 1986) & (Quaegebeur JM, et al. J Thorac Cardiovasc Surg 1986;92:361)

(Table from Kirklin JW, et al. Circ 1992;86:1501)

Laid-back view to image coronary anatomy in d-TGA

Wernovsky G & Sanders SP. Coronary artery anatomy and transposition of the great arteries. Coronary artery disease 1993;4:148-157

(Original publication: Mandell et al. Am J Cardiol 1990; 65:1379-1383)

Coronary artery anatomy in l-TGA:

Ref: Sequential diagnosis of coronary arterial anatomy in congenitally corrected transposition of great arteries. Ing-Sh Chiu et al. Ann Thorac Surg 2003;75:422-9.

This is an extensive paper. Will review this "soon".