Abstract
BackgroundImprovements in ultrasound technology has enabled direct, transthoracic visualization of long portions of coronary arteries : the left anterior descending (LAD), circumflex (Cx) and right coronary artery (RCA). Transthoracic measurements of coronary flow velocity were proved to be highly reproducible and correlated with invasive measurements. While clinical applications of transthoracic echocardiography (TTE) of principal coronary arteries are still very limited they will likely grow. The echocardiographers may therefore be interested to know the ultrasonic views, technique of examination and be aware where to look for coronary arteries and how to optimize the images.MethodsA step-by-step approach to direct, transthoracic visualization of the LAD, Cx and RCA is presented. The technique of examination is discussed, correlations with basic coronary angiography views and heart anatomy are shown and extensively illustrated with photographs and movie-pictures. Hints concerning optimization of ultrasound images are presented and artifacts of imaging are discussed.ConclusionsDirect, transthoracic examination of the LAD, Cx and RCA in adults is possible and may become a useful adjunct to other methods of coronary artery examination but studies are needed to establish its role.
Highlights
Improvements in ultrasound technology has enabled direct, transthoracic visualization of long portions of coronary arteries : the left anterior descending (LAD), circumflex (Cx) and right coronary artery (RCA)
Most of the studies has dealt with assessment of the middle and distal LAD which can be visualized in almost every patient [1,2,3,4,5,6,7,8] or the posterior interventricular branch, which in skilful hands can be assessed in 3/4 of patients [9]
That both Cx and RCA can be successfully assessed in a considerable number of sequential adults scheduled for coronary angiography [10,11] and it is known, that they can be studied in children [12,13]
Summary
We suggest to divide each coronary artery into three segments of approximately the same length (see Figs. 1,2,3,4,5, table 1). Slight change of the imaging plane so that it traverses the heart immediately below the pulmonary trunk allows for visualization of the left main (LM) and proximal LAD These arteries may be relatively visualized in B-mode while Doppler examination is usually required to locate the more distal parts of the LAD (Fig. 6,7,8,9, movie 1, 2 [see Additional file 1, 2]). The anterior wall of right ventricle at the coronary sulcus is carefully scanned and it is where good quality middle RCA images at low Doppler angles can be obtained (Fig. 34,35,36, movie 7 [see Additional file 7]). We have on a few occasions observed a characteristic artifact mimicking a very high velocity flow within the middle or distal LAD, which can be recorded both in color and spectral Doppler (Fig. 48,49, movie 11 [see Additional file 11]). The examination is technically demanding, but the feasibility of visualization of the LAD is high and moderate with regard to the Cx and RCA [[9,10,11,22], table 2]
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