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Briana Olson, RDCS, AE, PE09/25/2021Cardiology

Coronary Artery Imaging:

Don’t have a Heart Attack

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I do not have any disclosures

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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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Left Coronary Artery

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Right Coronary Artery

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Let’s see some pathology!

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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.

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Thank You!

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