Live three-dimensional transthoracic echocardiographic assessment of anomalous origin of left coronary artery from the pulmonary artery

We describe live three-dimensional transthoracic echocardiographic (3DTTE) findings in a 52-year-old female who had previously undergone an aortopulmonary tunnel operation for anomalous origin of the left coronary artery (ACA) from the pulmonary artery. Three-dimensional transthoracic echocardiography clearly delineated the origin of the ACA from the posterolateral aspect of the main pulmonary artery just above the pulmonary valve, the surgically created tunnel, as well as a small defect in the tunnel near the aortic end communicating with the pulmonary artery.     

Myocardial perfusion after aortic implantation for anomalous origin of the left coronary artery from the pulmonary artery

Postoperative myocardial perfusion and function were evaluated using thallium-201 myocardial imaging and technetium-99m cardiac pool imaging in five patients with an anomalous left coronary artery arising from the pulmonary artery. The patients underwent reimplantation of the left coronary artery at an age ranging from 10 months to 13 years. Postoperative electrocardiographic and radionuclide studies were performed both at rest and during stress 1 to 4 years after the operation. Electrocardiograms which were abnormal preoperatively returned to normal after surgery except that the T wave in lead aVL remained negative. Postoperatively, left ventricular ejection fraction measured by technetium-99m cardiac pool imaging was normal in all patients. Postoperative thallium-201 myocardial imaging, however, showed a perfusion defect with incomplete redistribution at the high-lateral or antero-lateral segment in all patients after a stress test. These data suggest that although myocardial ischaemic change decreases and global cardiac function improves after establishment of a dual coronary artery system, severe myocardial damage remains at the high-lateral or antero-lateral segment.     

Echocardiographic diagnosis of anomalous origin of the left coronary artery from the pulmonary artery

The objective of this study was to analyze echocardiographic characteristics of anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) and to explore the diagnostic value of transthoracic echocardiography. The echocardiographic characteristics of 8 patients hospitalized with ALCAPA from 2000 to 2005 were analyzed retrospectively, including the results of real time three-dimensional echocardiography in one case, and compared with angiographic results. Eight cases included 6 older type patients and 2 infant type patients. Echocardiography showed abnormal vessel inserting into pulmonary artery (PA), continuous shunt into PA and intercoronary collateral signals within the ventricular septum in all cases and bifurcate structure of the abnormal vessel with retrograde filling in 4 cases. The morphological and functional changes and valvular regurgitation induced by insufficient myocardial perfusion were also evaluated. In former 4 patients, 2 cases were misdiagnosed as right coronary artery-PA fistula and the other 2 cases were given an uncertain diagnosis of anomalous origin of the coronary artery because of the visualization of the echo-free linear structure which apparently arose from the aorta resembling a normal left coronary artery. The latter 4 patients were correctly diagnosed by excluding the aforementioned interference. The diagnosis of ALCAPA was confirmed by angiocardiography in all patients and by intraoperative findings in 4 patients. Based on the apprehension of ultrasonic features and the enhancement of diagnostic alertness, the echocardiography can evaluate ALCAPA accurately and give more information than angiography. It may be the first diagnostic choice.     

Imaging the elusive anomalous origin of left coronary artery from pulmonary artery

A 7‐year‐old girl with severe mitral regurgitation and pulmonary artery hypertension with good ventricular function was planned for mitral valve repair, but was subsequently diagnosed to have anomalous left coronary artery from pulmonary artery. We describe the pitfalls in the diagnosis of this rare anomaly, particularly in the presence of severe pulmonary artery hypertension and absence of circumstantial evidence of coronary steal and ventricular dysfunction.     

Diagnostic value of parasternal pulmonary artery short-axis view for the anomalous origin of the left coronary artery from the pulmonary artery

ObjectiveTo evaluate the diagnostic value of parasternal pulmonary artery (PA) short-axis view for the anomalous origin of left coronary artery (LCA) from the pulmonary artery by echocardiography.MethodsA total of 13 patients (3 boys) aged from 2 months to 12 years were enrolled. Transthoracic echocardiography, including cross-sectional imaging and color Doppler flow imaging, were performed, and their diagnoses were confirmed by operation.ResultsAmong the 13 patients, 7 had LCA originated from the left posterior wall of PA, 2 from the posterior wall, and 4 from the right posterior wall. The PA short-axis view could visualize the anomalous origin of the LCA from left posterior or posterior wall of PA clearly. The LCA and aortic wall were overlapping at 3–4 o’clock at PA short-axis view in the patients with LCA originating from the right posterior wall of PA. It was similar with the image of the LCA originating from the aorta. But the blood flow was opposite to that of LCA with normal origin.ConclusionsThe parasternal PA short-axis view is a good view to visualize the anomalous origin of the LCA.     

左冠状动脉异常起源于肺动脉的超声心动图诊断价值

目的:探讨左冠状动脉异常起源于肺动脉(ALCAPA)的超声心动图诊断价值。方法:以CTA和手术证实的16例ALCAPA患儿为研究对象,回顾分析其超声心动图表现特征。结果:16例中,超声首诊11例,误诊5例,5例均误诊为心内膜弹力纤维增生症(EFE),复诊检出3例,余2例最后经CTA检出,超声首诊正确率69%。其主要超声表现为:左冠状动脉主干异常开口于肺动脉;右冠状动脉扩张;左心室扩大;心内膜、二尖瓣腱索及乳头肌及回声增强。彩色多普勒显示左冠状动脉内血流为逆向灌注,肺动脉内舒张期见异常血流进入;室间隔可见异常交通循环血流信号。结论:ALCAPA具有特征性超声心动图表现,超声是早期诊断的重要手段。     

小儿左冠状动脉起源于肺动脉临床分析

目的:总结小儿左冠状动脉起源于肺动脉(ALCAPA)的临床特点,提高对ALCAPA的认识。方法:对2006年8月至2008年12月期间我院心脏中心门诊以"心内膜弹力纤维增生症"收治但最终诊断为ALCAPA的8例患者的临床特点、检查情况进行回顾性分析。结果:8例ALCAPA的患者女性7例,男性1例。发病年龄2～10个月,平均年龄5.3个月。8例患者均表现不同程度的气促、喘息、声哑、多汗及喂养困难等心力衰竭(心衰)症状。病初均于首诊医院误诊为心内膜弹力纤维增生症。患儿心电图、心脏超声及心脏增强CT均有较为特征性的改变。结论:小儿ALCAPA病例临床常易与心内膜弹力纤维增生症混淆。对于临床诊断心内膜弹力纤维增生症的患儿应注意其心电图表现。其中符合ALCAPA心电图特点的病例,反复探查其心脏彩超并进行心脏增强CT、心脏冠状动脉造影检查有助于ALCAPA的诊断。     

Anomalous origin of the left coronary artery from the right pulmonary artery: Report of a case

Summary A 1-year-old boy was referred to our hospital for further investigation of mitral regurgitation. Color-Doppler echocardiography revealed the site of the anomalous origin of the left coronary artery which was confirmed by a cineangiographic study. This case is interesting for several reasons: the first is that the anomalous left coronary artery originated from the right pulmonary artery; the second is that two-dimensional echocardiographic findings can be misleading, i.e., a vessel-like structure which seemed to be the left coronary artery arising normally from the aorta was visualized; and the last is that a two-dimensional color-Doppler echocardiogram was useful in the diagnosis of the anomalous origin of the left coronary artery. The patient underwent implantation of the anomalous left coronary artery as well as Kay's plasty of the mitral valve, and has been doing well since then.     

应用再植技术治疗起源异常左冠状动脉的效果分析

目的:分析和讨论应用冠状动脉再植技术治疗先天性起源于肺动脉的左冠状动脉异常(ALCAPA)的外科治疗效果和经验。方法:回顾分析2008年4月~2013年4月26例应用冠状动脉再植技术治疗先天性ALCAPA患儿的临床资料。其中男14例,女12例;年龄4月~6岁。术前均经超声心动图,CT和或心血管造影检查明确诊断。结果:术前左室射血分数(LVEF)20~80(48±18)%,心胸比0.54~0.77(0.64±0.07)。并发二尖瓣关闭不全(MI)轻度以上21例,其中中度以上17例。左心室心尖部室壁瘤1例,房间隔缺损1例。同期行二尖瓣成形11例,室壁瘤切除1例,房间隔缺损修补1例。本组患儿手术均顺利完成,无手术死亡。体外循环时间91~238(150±37)min,心肌阻断时间64~200(126±36)min。随访1~61(29±19)月,患儿无远期死亡。最后一次随诊LVEF35~75(64±11)%,心胸比0.48~0.65(0.57±0.05),较术前明显改善。MI中度以下24例。结论:冠状动脉再植技术手术效果良好,对于中度以上MI应积极治疗。     

Early variation of left ventricular dimension and mitral regurgitation after correction for anomalous origin of the left coronary artery from the pulmonary artery

Background Anomalous origin of the left coronary artery from the pulmonary artery is a rare congenital cardiac lesion resulting in myocardial ischemia even infarction,morphological impairment and dysfunction of left ventricle,together with mitral regurgitation.Here we will introduce our experience in the surgical repair of this kind of congenital lesion and the retrospective analysis about the improvement of left ventricular dimension and mitral regurgitation in early postoperative term.Method From May 1998 to July 2012,38 consecutive patients with anomalous coronary artery from the pulmonary artery underwent surgical correction(33 received left coronary artery re-implantation,4 left coronary artery ligation or primary closure,1 Takeuchi procedure,and 10 simultaneous mitral valve plasty).Left ventricular dimension,mitral regurgitation,and ejection fraction,were measured by color Doppler echocardiography preoperatively,and 1 month after discharge.Results Hospital survival was 94.7%(2 in-hospital deaths).Ten paptients with more than moderate mitral regurgitation received simultaneous mitral plasty,one of whom was converted to mechanical prosthetic valve replacement.Mitral valve annuloplasty was applied in 9 cases of coronary re-implantation correction,3 of whom also received additional mitral leaflet cleft repair.Meanwhile 8 patients underwent other different concomitant operations.Echocardiographic results for the survivals 1 month after discharge showed that left ventricular end-diastolic,endsystolic dimension decreased from 40.05 ± 5.56 mm and 28.94 ± 6.21 mm to 33.07 ± 6.82 mm(P < 0.01) and 23.04 ± 5.87 mm(P < 0.01) respectively.The average mitral regurgitation grade was also reduced from 2.36 ± 1.08 to 1.64 ± 93(P < 0.05) in the group.All survival patients improved clinically and NYHA functional class decreased significantly from 2.37 ± 1.08 to 2.10 ± 0.54(P < 0.05).Conclusions The surgical repair of anomalous origin of the left coronary artery from the pulmonary artery is safe and effective,and can get satisfactory dimensional and functional improvement of the left ventricle in early term.Although controversial,concomitant mitral valve plasty can be helpful for critical patients with severe mitral regurgitation.     

Magnetic resonance imaging of an anomalous origin of the left coronary artery from the pulmonary artery

This report describes a 34-year-old woman with an anomalousorigin of the left coronary artery from the pulmonary artery.The angiographic pattern was clearly demonstrated by magneticresonance imaging (MRI) performed before surgery. This casesuggests thst MRI could play an important role in the pre-operativeassessment of coronary anomalies.     

A rare case of anomalous origin of the left anterior descending artery from the pulmonary artery

Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) is a rare congenital heart disease, with an incidence of <1 in 300 000 live births. We describe a rare case of a 23‐month‐old infant admitted for cough and fever. Echocardiography showed a branch of the left coronary artery originating from the pulmonary artery. The coronary computed tomographic angiography revealed anomalous origin of the left anterior descending (LAD) artery from the pulmonary artery with the left circumflex artery and right coronary artery arising normally from the aorta. The infant successfully underwent surgical reimplantation of the LAD to the ascending aorta. Our case emphasizes that echocardiography and computed tomographic angiography are valuable imaging modalities for making an accurate diagnosis and determining the precise surgical plan.     

Echocardiographic diagnosis of anomalous origin of the left coronary artery from the pulmonary artery.

We found increased systolic coronary flow in transthoracic pulsed wave (PW) Doppler in a 42-year-old patient with anomalous origin of left main coronary artery from the pulmonary artery. This is a characteristic echocardiographic finding in this anomaly in the presence of collateral circulation and coronary L-R shunt. In comparison with so far used echocardiographic criteria this parameter when present allows quick recognition of anomalous origin of left coronary artery from the pulmonary artery, and its differentiation from other potentially lethal coronary anomalies.     

The role of echocardiography in anomalous origin of coronary artery from pulmonary artery (ALCAPA): Simple tool for a complex diagnosis

Anomalous origin of coronary artery from pulmonary artery (ALCAPA) is a rare coronary anomaly usually presenting in the first year of life. Adult presentation suggests a wide range of differential diagnosis such as myocarditis, dilated cardiomyopathy, and coronary artery disease. We have presented here the major distinctive echocardiographic features of ALCAPA through 4 cases. Since echocardiography is often used as the first imaging modality in these clinical scenarios, recognizing the characteristics of ALCAPA in a routine echocardiographic examination can transform a readily available, low‐cost tool into a valuable discriminative modality.     

Improvement in left ventricular dysfunction after aortic reimplantation in 11 consecutive paediatric patients with anomalous origin of the left coronary artery from the pulmonary artery: Early results of a serial echocardiographic follow-up

To study the potential for recovery of left ventricular functionin patients with anomalous origin of the left coronary arteryfrom the pulmonary artery (ALCAPA) after aortic reimplantation,serial two-dimensional echocardiographic examinations were performedbefore and up to 9 months after operation in 11 consecutivepaediatric patients (group 1: six infants; group 2: five childrenabove the age of 1 year). End-diastolic volume (EDV), end-systolicvolume (ESV), stroke volume (SV), ejection fraction (EF), myocardialvolume (MV), ratio of myocardial volume!end-diastolic volume(MVI), and regional wall motion of the left ventricle (LV) werestudied. Pre-operativety, mean LVEDV was 339% of normal in group 1 and289% in group 2 (P<0.001); mean LVMV was about twice thenormal value in both groups (P<0.001); LVMVI was 0–79± 0–23 in group 1 and 0–83 ± 0–3in group 2; LVEF was 28 ± 10% in group 1 and 46 ±18% in group 2; regional wall motion was normal in two group2 patients, the other showed uniform reduction in segmentalshortening fraction. Postoperatively, mean LVEDV tended to become normal after 2weeks in group 1 and after 3 months in group 2. In both groupsmean LVEF reached the normal range after 3 months; LVMV as wellas LVMVI normalized after 9 months. Three months after the operation,all infants had a nearly normal pattern of regional wall motion,while in three group 2 children a residual reduced shorteningfraction could be observed in anterior or lateral segments. The study shows that (1) aortic reimplantation in patients withALCAPA results in progressive improvement left ventricular functioneven in patients with severely damaged myocardium. (2) For aquick and complete recovery of global and regional left ventricularfunction, the operation should be undertaken early in infancy.(3) Left ventricular dysfunction is probably associated with‘hibernating myocardium’, which may ‘wakeup’ after surgical repair.     

Effects of coronary artery narrowing,collaterals, and left ventricular function on the pattern of myocardial perfusion

We evaluated effects of the degree of diameter narrowing of the coronary arteries (50–69%, 70–89%, ≥90%); extent of coronary disease [one-vessel disease (1VD), two-vessel (2VD), three-vessel (3VD)]; collaterals; and left ventricular function on the pattern of exercise thallium-201 perfusion in 121 patients; 30 patients with normal coronary angiograms, 37 with 1VD, 24 with 2VD, and 30 with 3VD. Fifteen patients had Q waves on ECG, 29 patients had akinetic segments on the left ventriculogram, and 46 patients had collaterals. The results suggest the following: 1) Patients with 59–69% narrowing of one vessel have normal exercise perfusion. 2) All patients with 1VD have abnormal exercise perfusion if the degree of narrowing is ≥90%, unless the right coronary artery (RCA) is the vessel involved. 3) Patients with 2VD and 3VD generally have abnormal exercise perfusion unless all the narrowings are <90%, or the RCA is the only vessel with ≥90% narrowing, or the stress is submaximal. 4) Collaterals do not protect against development of abnormal exercise perfusion; they feed the most severely narrowed vessel, and perfusion abnormalities are ordinarily seen in the distribution of such severely narrowed vessels. 5) Neither the presence of Q waves on the ECG nor an akinetic segment on the left ventriculogram correlates with defects in the redistribution images; residual defects may be seen in the delayed images despite the absence of prior myocardial infarction, and normal images may be seen despite the presence of akinetic segments in the left ventriculogram.     

Myocardial infarction in the distribution of a patent anomalous left circumflex coronary artery

Anomalous origin of the left circumflex coronary artery is the most common congenital coronary artery anomaly. Myocardial infarction has been seen in the distribution of this anomalous vessel. This has been noted most typically when the vessel is atherosclerotic. Sudden death and myocardial infarction, however, also have been seen in a case without atherosclerotic involvement. This is a case report of a 45-year-old man who suffered a myocardial infarction after strenuous and sustained physical effort and who was found to have nonatherosclerotic coronary arteries with an anomalous left circumflex coronary artery arising from the right sinus of Valsalva.     

Myocardial bridging of the left anterior descending artery: Evaluation using exercise thallium-201 myocardial scintigraphy

Seven patients with myocardial bridging of the left anterior descending coronary artery were evaluated by means of thallium-201 exercise scintigraphy. The degree of systolic narrowing was 60–70% in five patients and 75–80% in two patients. All patients had presented with chest pain. The resting electrocardiogram was normal in six patients; there were ST segment and T-wave abnormalities in one patient. No patient complained of chest pain during exercise. The exercise electrocardiogram was negative in six patients and inconclusive in one patient. Exercise myocardial scans were negative in all seven patients. We conclude that no evidence of ischemia was demonstrated in patients with myocardial bridging of the left anterior descending coronary artery as determined by exercise electrocardiography and stress thallium-201 scintigraphy.     

Pulmonary artery origin of the left coronary artery: diagnosis by transoesophageal echocardiography in infancy

In two infants the anomalous origin of the left coronary arteryfrom the pulmonary artery (ALCAPA) was detected prospectivelyby transoesophageal echocardiography (TEE). Colour flow mappingand pulsed Doppler ultrasound revealed a predominant right-to-leftshunt from the pulmonary artery to the left coronary artery.These findings were confirmed by angiography. Transihoracic echocardiography (TTE)failed to show the anomalousorigin of the left coronary artery or any abnormal pulmonaryflow pattern. TEE may be useful in the diagnosis of ALCAPA in selected cases,when TTE is inconclusive.