Briana Olson, RDCS, AE, PE 09/25/2021 Cardiology Coronary Artery Imaging: Don’t have a Heart Attack
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Briana Olson, RDCS, AE, PE09/25/2021Cardiology
Coronary Artery Imaging:
Don’t have a Heart Attack
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Why Should We Look at Coronaries?
• Current guidelines published by ASE list imaging
of coronary arteries (CA) as standard component
of a pediatric echocardiogram*
• Abnormal CA origins are associated with an
increased risk of sudden cardiac death**
• Detailed CA imaging of pediatric patients
presenting with syncope, chest pain with
exercise, exercise-induced arrythmias, and
Kawasaki disease is necessary**
• High-quality diagnostic imaging of coronaries can
present a significant challenge for sonographers* Wyman, JASE, 2006
** Brown et al, JASE, 2015
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What We Will Discuss Today
• Coronary artery anatomy
• Knobology and image optimization
• What is important to show the reading
physicians
• Look at normal coronary images
• Brief look at selected coronary artery pathology
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• Know your coronary artery anatomy!
• Know the limitations of imaging CA using
ultrasound
• Can use non-standard views at times
Where to Start
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Coronary Artery Anatomy
• Left main coronary artery originates from the left
coronary sinus
• Gives rise to the left anterior descending and
circumflex
• Right coronary artery from the right coronary
sinus
source: https://sems-journal.ch/6297
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Knobology and Image Optimization
• Start with the highest frequency transducer relative
to patient size
• Better resolution
• Coronaries are superficial structures
• Turn down the compression to the high 30’s or low
40’s for a high-contrast image (very black & white)
• Reduce depth / sector size (or zoom) to include the
coronary in question and aortic valve for context
• Increases frame rate
• Adjust focal zone
• Harmonics
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Knobology and Image Optimization
• Turn your Color Doppler setting to ‘high flow’
optimization and start with a Nyquist of about 30
cm/sec
• Velocity within coronaries is very low so this will color fill
the coronaries more easily
• Only turn the scale as low as needed so the direction of
flow does not alias
• Use a small sector color box only over the area of interest
• Persistence
• Turn your EKG on!
diastole
• Coronaries fill in predominantly in diastole
• Have it gained enough to see
the cardiac cycle
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• Interrogate the left and right independently
• Prove the origin of each coronary arises from the
appropriate aortic Sinus of Valsalva
• Prove they have a normal proximal course
• Confirm direction of flow by color Doppler
What Are You Trying to Show the Reading
Physicians?
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What Are You Trying to Show the Reading
Physicians?
• Left coronary
• Left main originates at about 4 o’clock
• Usually ‘tubed out’ by a slight clockwise rotation
• Right coronary
• Right coronary originates about 10 o’clock
• Usually more difficult to see!
• Often counterclockwise
rotation
• Roll patient flat or right
lateral decubitus with
right sternal border
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What Are You Trying to Show the Reading
Physicians?
• Demonstrate in 2D as well as with color Doppler• Color compare is an excellent tool
• Show color originating from the lumen of the
aortic root into the coronary artery • Keep color sector small, only over area of interest
• Parasternal short axis at or just superior to the level of the aortic
valve
• Keep in mind your angle of interrogation. Sometimes moving
up/down or medial/lateral on the chest will help the coronary fill
with color
• Avoid clipping still-frames alone. Always store a
moving clip first and then a still-frame when
appropriate
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Is This Normal?
• Anomalous right coronary artery from the
left coronary cusp
• Incidence of <1% of the population
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Is This Normal?
• Anomalous left coronary artery from the
right coronary cusp
• Incidence of 0.15% of the population
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Is This Normal?
• ALCAPA (anomalous left coronary artery
from pulmonary artery)
• Flow reversal confirmed by color cine loop
• Absence of left coronary artery ostium
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Is This Normal?
• Large coronary artery aneurysms, as can be seen with
Kawasaki disease
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Is This Normal?
• Diffusely dilated visualized portions of the left and
right coronary arteries, as seen in another patient with
Kawasaki Disease
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Conclusions
• Know your CA anatomy, machine settings, and
views to obtain the best quality images
• Use critical thinking to answer the study question
• Practice! Practice imaging CAs in compliant
patients on a regular basis
• Can save patients from more invasive or costly
diagnostic tests
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References
• Brown LM, Duffy CE, Mitchell C, & Young L. A Practical Guide to
Pediatric Coronary Artery Imaging with Echocardiography. JASE.
2015;28(4):379-391. doi:10.1016/j.echo.2015.01.008.
• Wyman WL, Tal G, Girish SS, et al. Guidelines and Standards for
Performance of a Pediatric Echocardiogram: A Report from the Task
Force of the Pediatric Council of the American Society of
Echocardiography. JASE. 2006;19(12):1413-1430.
doi:10.1016/j.echo.2006.09.001.