Bricelj, Vladimir

Robida, Andrej

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UNIVERSITY CLINICAL CENTER LJUBLJANA, UNIVERSITY PEDIATRIC HOSPITAL, DEPARTMENT OF PEDIATRIC CARDIOLOGY IDENTIFICATION OF ENLARGED CONAL ARTERY IN TETRALOGY OF FALLOT WITH SECTOR SCAN ECHOCARDIOGRAPHY Robida A, Bricelj V Abstract- In a 9-month-old boy with tetralogy of Fallot, prominent conal branch of the right coronary artery traversing the right ventricular outflow tract was visualized with sector scan echocardiography. Angiography in the aortic root confirmed the echocardiographic diagnosis. The advantage of nonin­vasive diagnosis of these anomalies is in postponing angicardiography and surgery in cases of tatralogy of Follot when major bran eh of the coronary artery crosses the right ventricular outflow tract. An alternative palliative operation may be necessary in such patients. UDC: 616.124.6-007.253-073:534-8 Key words: tetralogy of Fallot, coronary vessel anomalies, echocardiography Case report Radiol lugosl 1989; 23: 365-7 lntroduction - In 5-9 % of patients with tetra­logy of Fallot, anterior descending coronary ar­tery or another major branch crosses the right ventricular outflow tract (1, 2). When total correc­tion is planned, the right ventricular outflow tract or transanular patch must be frequently used especially in infants. The anomalous artery can be seve red at the tirne of right ventricular outflow tract incision and fatalities may occur. Thus preoperative delineation of coronary arteries is essential. Routinely employed aortic root angio­graphy with a venous catheter passed through ventricular septal defect, or if this fails, with a retrograde catheter usually satisfactorily shows the coronary arteries. Sector scan echocardiography has been used to assess the coronary arteries in .transposition of great arteries (3). In this report we describe the sector scan echocardiographic imaging of prominent conal artery branch of the right coronary artery cros­sing the right ventricular outflow tract in tetralogy of Fallot. Fig. 1 a-Short axis parasternal view of the left anterior descending coronary artery (lad) and circumflex bran eh of the left coronary artery (cir). AO = aorta, PA= Case report - A 9-month-old boy with dia­gnosis of tetralogy of Fallot was presented to us at the age of 4 months with the episodes of cya­notic spells. At that tirne he was started on pro-Received: July 3, 1989 - Accepted: July 27, 1989 = pulmonary artery. pranolol and received the transfusion of packed red cells because of anemia. Cyanotic spells reappeared a few days before his second admission. Sector scan echocardio-365 Robida A, Bricelj V. ldentification of enlarged conal artery in tetralogy of Fallot with sector scan echocardiography Fig. 1 b - Short axis parasternal view of the conal branch (cb) of the right coronary artery crossing the right ventricular outflow tract. AO = aorta, PA= pul-monary artery. �'<:�-' ) �-, �� ..,./, ' ·- ·. . Fig. 2 - Aortic root angiography showing the conal branch (arrow) of the right coronary artery (rca) which crosses the right ventricular outflow tract. graphy revealed typical features of tetralogy of Fallot with pronounced infundibular stenosis. Special attention was paid to the examination of the coronary arteries. We used 5 MHz medium focus transducer from high left parasternal short axis view just above the aortic valve (1). To see the left coronary artery the transducer was orien­ted inferiorly so that the pulmonary valve annu­lus was shown on cross section. Anticlockwise rotation of the transducer revealed prominent conal branch of the right coronary artery (Fig. 1 366 a, b). Cardiac catheterization and angiocardio­graphy confirmed echocardiographic diagnosis of tetralogy of Fallot. lnjection of the contrast medi um into the aortic root in left anterior obli­que projection of 45 degrees and cranial angula­tion of 20 degrees showed the right coronary artery and the conal branch crossing the right ventricular outflow tract (Fig. 2). Discussion - Recent report on the echocar­diographic examination of the anomalies of the coronary arteries in tetralogy of Fallot has identi­fied coronary arteries in 78 % of studied children. Major obstacles for adequate imaging of coro­nary arteries in this defect have been poor pene­tration of ultrasound beam in large patients, concomitant pulmonary disease with persistent overlaying of lung tissue, and pulmonary artery atresia with severe hypoplasia of the right ventri­cular outflow tract. The anomalies have been found in 9 of 29 studied children. Only in one patient a small conal branch has been visualized. It has not been considered ab­normal (4). However, conal branch of the right coronary artery in tetralogy of Fallot tends to be long and swings lower over the right ventricular outflow tract instead of being short and high as is the case in normal situation. The enlarged conal artery is the response to right ventricular hyper­trophy. It may render right ventriculotomy unde­sirable (1, 5). Surgeon can usually identifiy ano­malies of the coronary arteries during surgery but sometimes these may be obscured by adhe­sions of previous operations or may run intra-murally. Thus the advantage of sector scan echocar­diographic examination of the coronary arteries is in postponing the invasive investigation and surgery in cases of tetralogy of Fallot where ma­jor coronary artery crosses the right ventricular outflow tract. An alternative palliative operation may be indicated in such patients. Povzetek PRIKAZ POVEČANE KONUSNE ARTERIJE PRI TETRALOGIJI FALLOT Z DVODIMENZIONALNO EHOKARDIOGRAFIJO Pri 9 mesečnem dečku s tetralogijo Fallot sva prika­zala povečano konusno arterijo, ki je prečkala iztočni trakt desnega prekata z dvodimenzionalno ehokardio­grafijo. Diagnozo sva potrdila z angiografijo v aortni koren. Prednost neinvazivne ehokardiografske dia­gnostike prikaza koronarnih arterij je v preložitvi inva­zivne diagnostike in kirurškega posega pri bolnikih s teralogijo Fallot, kjer večja koronarna arterija prečka iztočni trakt desnega prekata. Včasih je pri teh pacien­tih potrebno napraviti alternativno paliativno operacijo. Radiol lugosl 1989; 23: 365-7 Robida A, Bricelj V. ldentification of enlarged conal artery in tetralogy of Fallot with sector scan echocardiography R e fe r e n c e s  1. White I R, Frech RS, Castaneda A, Amplatz K. The nature and significance of anomalous coronary arte­ries in tetralogy of Fallot. Am J Roentgenol Rad The­rapy Nuclear Med 1972; 114: 350-4. 4. Berry J M, Einzig S, Krabill K A, Bass J L. Evalua­tion of coronary artery anatomy in patients with tetra­logy of Fallot by two-dimensional echocardiography. Circulation 1988; 78: 149-56. 2. Fellows K E, Smith J, Keane F. Preoperative an­giography in infants with tetralogy of Fallot. Am J Car­diol 1981; 47: 1279-85. 5. Hurwitz R A, Smith W, King H, Girod GA, CaldwellR L. Tetralogy of Fallot with abnormal coronary artery: 1967-1977. J Thorac Cardiovasc Surg 1980; 80: 129-34.3. Pasquini L, Sanders S P, Parness I A, Olan S D. Diagnosis of coronary artery anatomy by two-dimen­sional echocardiography in patients with transposition of the great arteries. Circulation 1987; 75: 557-64. Author's address: Robida Andrej M. D., University Clinical Center Ljubljana, Zaloška 2, 61000 Ljubljana. 27th Congress of the European Society of Paediatric Radiology The European Society of Paediatric Radiology is holding its 27th Congress, May 14-19, 1990, in Munich, Germany. The meeting will have a well balanced scientific programme covering all aspects of paediatric radiology, state-of-the-art techniques in diagnostic and inter­ventional imaging, quality assurance and professional practice. Special programmes include a »two days before« industrial visit to Siemens (May 11) and Philips (May 12) with subsequent city sightseeing tour of Erlangen-Nurnberg and Salzburg, a postgraduate course (May 14 & 15) based on the theme »Rational use of diagnostic imaging in paediatrics«, an international Symposium on »The Status of paediatric radiology in Europe«. Accompanying programmes include a companion's confe­rence (May 16) on »Bavaria - History, art and modem lite« and a post congress tour of the cultural and scenic highlights of Bavaria (May 19 & 20), Deadlines: Papers and posters, Dec. 31, 1989; registration, March 1, 1990. Fees (tentative) Postgraduate course: DM 250; Congress Non-Mem­bers - regular DM 400 / reduced (students and trainees) DM 250; members of the ESPR - regular DM 350 / reduced DM 200. lnformation: Dr. H. Fendel, Univ.-Kinderklinik, Rbntgenabteilung, Lind­wurmstr. 4, D-8000 Munchen 2, Federal Republic of Germany, Fax. (89) 5160-5388, Tel. (89) 5160-3161.Radiol lugosl 1989; 23: 365-7 367 

Identification of enlarged conal artery in tetralogy of Fallot with sector scan echocardiography

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Identification of enlarged conal artery in tetralogy of Fallot with sector scan echocardiography

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