Diagnostic value of echocardiography on detecting the various types of anomalous origin of the left coronary artery from the pulmonary artery

Abstract

Background: To assess the diagnostic value of echocardiography in detecting the various types of anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA).

Methods: A total of 30 patients with an established diagnosis of ALCAPA were retrospectively analyzed, and classified into infant- (n=20) and adult-type (n=10) groups according to the age of symptom manifestation and the mode of presentation. All patients underwent echocardiography examination.

Results: Twenty-four out of thirty patients were diagnosed with ALCAPA by echocardiography. The remaining six cases were confirmed by dual-source computed tomography (DSCT) and angiocardiography, respectively. In the infant-type group, there was negligible or no collateral flow between the right coronary artery (RCA) and the left coronary artery (LCA). Eighteen of these patients had enhanced echogenicity of left ventricular (LV) papillary muscles, different degrees of mitral regurgitation (MR) and the RCA to aortic annulus ratio (RCA/AO) was >0.12. In the adult-type group, all ten patients had RCA dilation and significant development of collateralization from the RCA to the dilated LCA. They all had mild MR and RCA/AO was >0.20. Preoperatively, left ventricular ejection fraction (LVEF) was significantly lower in infant-type group than in adult-type group (46.24%±5.47% vs. 61.43%±6.38%, P<0.01). Cardiac surgery significantly improved post-operative LVEF (60.12%±6.02%, P<0.01 vs. pre-operation) in infant-type group.

Conclusions: Echocardiography plays a pivotal role in detecting ALCAPA. Imaging and clinical features differ significantly between infant- and adult-type cases.

Keywords: Echocardiography; adult; anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA); infant.

Figure 1

ALCAPA detected by echocardiography. Female, 37 years old, adult-type ALCAPA. (A) Echocardiography showing the left coronary artery originating from the posterior wall of the pulmonary trunk (arrow); (B) shunting flow from the left coronary artery into the pulmonary artery (arrow). ALCAPA, anomalous origin of the left coronary artery from the pulmonary artery; LCA, left coronary artery; PA, pulmonary artery.

Figure 2

Characteristic findings of infant-type ALCAPA. Male, 1 year old. (A) Less coronary collaterals within the ventricular septum (arrow); (B) echogenic enhancement in LV papillary muscles (arrows), especially in the anterolateral papillary muscle; (C) echocardiography showing left ventricle dilation, and anterior leaflet prolapse of the mitral valve with moderate to severe regurgitation (arrow); (D) coronary angiography showing a slightly dilated right coronary artery (arrow) arising from the aortic sinus, and right coronary supplying collaterals to the LCA (arrow), which drains to the pulmonary artery. ALCAPA, anomalous origin of the left coronary artery from the pulmonary artery; LV, left ventricle; MR, mitral valve regurgitation; RCA, right coronary artery; AO, aorta.

Figure 3

Characteristic findings of adult-type ALCAPA. Female, 37 years old. (A) Parasternal long-axis view, color Doppler imaging revealing multiple coronary collaterals within the ventricular septum and free ventricular wall (arrows); (B) echocardiography at parasternal short axis showing papillary muscles without echogenic enhancement (arrows); (C) echocardiography at the apical 4-chamber view showing the mitral valve with slight regurgitation (arrow); (D) coronary angiography showing a markedly dilated right coronary artery (arrow) arising from the aortic sinus, and the left coronary artery (arrow) being filled from collaterals and shunting into the pulmonary artery. ALCAPA, anomalous origin of the left coronary artery from the pulmonary artery; RV, right ventricle; RA, right atrium.