Non-invasive imaging of coronary arteries by transthoracic echocardiography is an emerging diagnostic tool to study the left main (LM), left descending artery (LAD), circumflex (Cx) and right coronary artery (RCA). Impaired coronary circulation can be assessed by measuring coronary velocity flow reserve (CVFR) by transthoracic Doppler echocardiography. Coronary artery stenoses can be identified as localized colour aliasing and accelerated flow velocities. We report a case with an acute coronary syndrome (ACS) of a 46-year-old man. With non-invasive imaging of coronary arteries by transthoracic echocardiography (TTE), we identified a segment of the mid right coronary artery (RCA) suggestive of stenosis with localized colour aliasing and accelerated flow velocity. We found a high ratio between the stenotic peak velocity and the prestenotic peak velocity, and a pathologic coronary flow velocity reserve (CFVR) distal to the stenosis in the posterior interventricular descending branch (RDP). Subsequent coronary angiography demonstrated one vessel disease with a stenosis in segment 3 of RCA, which was successfully treated with percutaneos coronary intervention PCI. Two weeks following the PCI procedure he was readmitted to hospital with chest pain. A subacute stent thrombosis was questioned, and repeated echocardiography was preformed. The mid portion of RCA showed normal and laminar flow. The CVFR of RCA measured in the RDP showed normal vasodilatory response, confirming an open RCA without any flow limitation. A repeated coronary angiogram demonstrated only a mild in stent intimal hyperplasia. This case illustrates the value of transthoracic echocardiography as a tool both in the diagnosis and the follow-up of chest pain disorders and coronary flow problems. Transthoracic echocardiography allows both direct visualization of the various coronary segments and assessment of the CVFR

Espen Holte

F Rigo

H Lethen

Johnny Vegsundvåg

K Tokai

M Krzanowski

M Saraste

Rune Wiseth

T Hozumi

Y Matsumura

English

PubMed

Crossref

Direct visualization of a significant stenosis of the right coronary artery by transthoracic echocardiography. A case report

Abstract Non-invasive imaging of coronary arteries by transthoracic echocardiography is an emerging diagnostic tool to study the left main (LM), left descending artery (LAD), circumflex (Cx) and right coronary artery (RCA). Impaired coronary circulation can be assessed by measuring coronary velocity flow reserve (CVFR) by transthoracic Doppler echocardiography. Coronary artery stenoses can be identified as localized colour aliasing and accelerated flow velocities. We report a case with an acute coronary syndrome (ACS) of a 46-year-old man. With non-invasive imaging of coronary arteries by transthoracic echocardiography (TTE), we identified a segment of the mid right coronary artery (RCA) suggestive of stenosis with localized colour aliasing and accelerated flow velocity. We found a high ratio between the stenotic peak velocity and the prestenotic peak velocity, and a pathologic coronary flow velocity reserve (CFVR) distal to the stenosis in the posterior interventricular descending branch (RDP). Subsequent coronary angiography demonstrated one vessel disease with a stenosis in segment 3 of RCA, which was successfully treated with percutaneos coronary intervention PCI. Two weeks following the PCI procedure he was readmitted to hospital with chest pain. A subacute stent thrombosis was questioned, and repeated echocardiography was preformed. The mid portion of RCA showed normal and laminar flow. The CVFR of RCA measured in the RDP showed normal vasodilatory response, confirming an open RCA without any flow limitation. A repeated coronary angiogram demonstrated only a mild in stent intimal hyperplasia. This case illustrates the value of transthoracic echocardiography as a tool both in the diagnosis and the follow-up of chest pain disorders and coronary flow problems. Transthoracic echocardiography allows both direct visualization of the various coronary segments and assessment of the CVFR.</p

Wiseth Rune

Vegsundvåg Johnny

Holte Espen

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BioMed CentralCardiovascular Ultrasound
ssOpen AcceCase report
Direct visualization of a significant stenosis of the right coronary 
artery by transthoracic echocardiography. A case report
Espen Holte*1, Johnny Vegsundvåg1 and Rune Wiseth2,3
Address: 1Department of Internal Medicine, Ålesund Hospital, Ålesund, Norway, 2Department of Circulation and Medical Imaging, Norwegian 
University of  Science and Technology, Trondheim, Norway and 3Department of Cardiology, Trondheim University Hospital, Trondheim, Norway
Email: Espen Holte* - es-holte@online.no; Johnny Vegsundvåg - johnnyvegsundvag@adsl.no; Rune Wiseth - rune.wiseth@ntnu.no
* Corresponding author    
Abstract
Non-invasive imaging of coronary arteries by transthoracic echocardiography is an emerging
diagnostic tool to study the left main (LM), left descending artery (LAD), circumflex (Cx) and right
coronary artery (RCA). Impaired coronary circulation can be assessed by measuring coronary
velocity flow reserve (CVFR) by transthoracic Doppler echocardiography. Coronary artery
stenoses can be identified as localized colour aliasing and accelerated flow velocities. We report a
case with an acute coronary syndrome (ACS) of a 46-year-old man. With non-invasive imaging of
coronary arteries by transthoracic echocardiography (TTE), we identified a segment of the mid
right coronary artery (RCA) suggestive of stenosis with localized colour aliasing and accelerated
flow velocity. We found a high ratio between the stenotic peak velocity and the prestenotic peak
velocity, and a pathologic coronary flow velocity reserve (CFVR) distal to the stenosis in the
posterior interventricular descending branch (RDP). Subsequent coronary angiography
demonstrated one vessel disease with a stenosis in segment 3 of RCA, which was successfully
treated with percutaneos coronary intervention PCI. Two weeks following the PCI procedure he
was readmitted to hospital with chest pain. A subacute stent thrombosis was questioned, and
repeated echocardiography was preformed. The mid portion of RCA showed normal and laminar
flow. The CVFR of RCA measured in the RDP showed normal vasodilatory response, confirming
an open RCA without any flow limitation. A repeated coronary angiogram demonstrated only a
mild in stent intimal hyperplasia. This case illustrates the value of transthoracic echocardiography
as a tool both in the diagnosis and the follow-up of chest pain disorders and coronary flow
problems. Transthoracic echocardiography allows both direct visualization of the various coronary
segments and assessment of the CVFR.
Published: 1 October 2007
Cardiovascular Ultrasound 2007, 5:33 doi:10.1186/1476-7120-5-33
Received: 26 July 2007
Accepted: 1 October 2007
This article is available from: http://www.cardiovascularultrasound.com/content/5/1/33
© 2007 Holte et al; licensee BioMed Central Ltd. 
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), 
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 5
(page number not for citation purposes)
Cardiovascular Ultrasound 2007, 5:33 http://www.cardiovascularultrasound.com/content/5/1/33Background
Non-invasive imaging of coronary arteries by transtho-
racic echocardiography is an emerging diagnostic tool to
study the left main (LM), left descending artery (LAD), cir-
cumflex (Cx) and right coronary artery (RCA) [1].
Impaired coronary circulation can be assessed by measur-
ing coronary velocity flow reserve (CVFR) by transthoracic
Doppler echocardiography [2-4]. Coronary artery sten-
oses can be identified as localized colour aliasing and
accelerated flow velocities [5,6]. We report a case with an
acute coronary syndrome (ACS), where transthoracic
echocardiography showed a significant stenosis of the
middle part of the RCA, confirmed by pathologic CVFR
measured in the posterior interventricular descending
branch (RDP) and by coronary angiography. The stenosis
was successfully treated by percutaneos coronary interven-
tion (PCI) with drug eluting stent. The patient was read-
mitted to hospital 2 weeks later after a new episode of
chest pain. Transthoracic echocardiography did not indi-
cate stent related flow reduction with normal CVFR of the
RDP. Coronary angiography performed 3 months later
demonstrated minor in stent intimal hyperplasia with no
significant stenosis.
Case presentation
A 46-year-old man presented with typical retrosternal
chest pain compatible with ACS. ECG was normal while
cardiac troponin I was slightly elevated at 0.06 μcg/L(≤
0.04 μcg/L as normal reference). He was treated with ace-
tylsalicylic acid, clopidogrel, atorvastatin, carvedilol, and
subcutaneous enoxaparin. There were no episodes of
recurrent chest pain.
The patient was admitted to our hospital during a pilot
phase of a study comparing transthoracic coronary flow
measurements by ultrasound with results obtained at cor-
onary angiography. Accordingly, the patient was exam-
ined with an Acuson Sequoia c 512 (Siemens Medical
Solutions USA, Inc) ultrasound system connected to a
standard 3.5 MHz transthoracic transducer. Left ventricu-
lar contractility was normal. With the use of all standard
and modified apical, parasternal and subcostal views [5],
we identified by colour flow Doppler the LM, the proxi-
mal, mid and distal segment of the LAD, the proximal and
mid segment of the Cx, the proximal, mid and distal seg-
ments of the RCA, and the RDP. The velocity scale was set
to 0.24 m/s, but was actively changed. Angle correction
was used. Contrast agent was not used.
The LM, LAD, proximal and mid segments of the Cx, RDP
and proximal segment of RCA showed laminar flow and
normal flow velocities, without any signs of colour-alias-
ing suggestive of stenosis. In the subcostal 4-chamber
view we identified a segment of the mid RCA with colour-
aliasing (Figure 1), and the diastolic peak velocity meas-
ured with pulsed wave Doppler was 1.39 m/s (Figure 1).
These findings were confirmed with the use of a modified
subcostal short axis view. The flow acceleration was quan-
tified as the ratio of peak diastolic flow velocity at the site
of aliasing to nearest upstream non-accelerated presten-
otic peak diastolic flow velocity. This ratio was 3.75 (Table
1), compatible with a significant stenosis in the mid RCA.
From a modified apical 2-chamber view the CVFR was
measured both in the RDP and the distal segment of LAD,
and hyperaemic flow was obtained by venous infusion of
In the modified subcostal four-chamber window we identified a segment of the mid RCA with colour-aliasing suggestive for a stenosisFigure 1
In the modified subcostal four-chamber window we identified a segment of the mid RCA with colour-aliasing suggestive for a 
stenosis. Stenotic diastolic peak velocity measured with pulsed wave Doppler 1.39 m/s, in a modified subcostal four chamber 
view.Page 2 of 5
(page number not for citation purposes)
Cardiovascular Ultrasound 2007, 5:33 http://www.cardiovascularultrasound.com/content/5/1/33adenosine (140 μcg/kg/min). The CVFR of the LAD was
normal (Table 1), indicating that the LAD was open with
good microvascular function and without any significant
stenosis. The CVFR value of 1.17 measured in the RDP was
clearly pathologic (Table 1, Figure 2), indicating an
obstructive lesion proximal to the RDP, most likely in the
mid segment of the RCA.
Subsequent coronary angiography demonstrated one ves-
sel disease with a stenosis in segment 3 of the right coro-
nary artery (Figure 3). The location of the stenosis
correlated well with our echocardiographic description.
The stenosis was successfully treated with PCI and
implantation of a drug eluting stent (Figure 4).
Two weeks following the PCI procedure the patient was
readmitted to hospital with chest pain. ECG and level of
cardiac troponin I was normal. A subacute stent thrombo-
sis was questioned, and a repeated echocardiography was
performed. The mid portion of the RCA was thoroughly
scanned, with findings of normal and laminar flow with-
out any colour flow aliasing, suggestive of no flow impair-
ment at the stented segment. Repeated CVFR of the RDP
showed a normal vasodilatory response (Table 1, Figure
5), confirming an open RCA without any flow limitation.
A more thorough clinical assessment concluded with tho-
racic myalgia as the probable cause of his recent chest
pain. Nevertheless, a repeated coronary angiogram was
performed three months later demonstrating only mild in
stent intimal hyperplasia.
Discussion
Several recent reports have documented the feasibility of
visualizing most segments of the main coronary arteries
by transthoracic echocardiography [1,5]. By this tech-
nique, coronary stenoses typically show local flow acceler-
ation and turbulence expressed as colour aliasing by
colour flow Doppler and accelerated flow velocities across
Table 1: Measurements
1 SPDV: 1.39 m/s PPDV: 0.37 m/s RatioSPDV/PPDV = 3.75
Flow velocity at baseline Flow velocity at adenosine Ratioadenosine/baseline
2 0.28 m/s 0.78 m/s CFVRLAD = 2.78
3 0.41 m/s 0.48 m/s CFVRRDP = 1.17
4 0.38 m/s 0.83 m/s CFVRRDP = 2.18
1: Ratio between the stenotic peak velocity (SPDV) and the prestenotic peak velocity (PPDV)
2: Coronary flow velocity reserve of the LAD
3: Coronary flow velocity reserve of the RDP before PCI
4: Coronary flow velocity reserve of the RDP at readmission
CVFR of RDPFigure 2
CVFR of RDP. Peak diastolic velocity of RDP baseline 0.41 m/s. Peak diastolic velocity of RDP adenosine (enveloped) 0.48 m/s.Page 3 of 5
(page number not for citation purposes)
Cardiovascular Ultrasound 2007, 5:33 http://www.cardiovascularultrasound.com/content/5/1/33the stenosis [5,6]. To assess the severity of the stenoses,
flow acceleration can be quantified by comparing flow
velocities at the site of aliasing with nearest upstream non-
accelerated prestenotic flow velocities [5,7]. A maximal-
to-prestenotic peak diastolic flow velocity ratio greater
than 2.0 predicts significant stenosis with high sensitivity
and specificity [5]. Our patient demonstrated in the mid
RCA a significantly accelerated flow velocity of 1.39 m/s
(Figure 1) and an elevated maximal-to-prestenotic ratio of
3.75 (Table 1), compatible with a significant stenosis in
this segment. This was confirmed by coronary angiogra-
phy (Figure 3). A comprehensive examination of the cor-
onary arteries by transthoracic echocardiography did not
reveal other stenoses, as confirmed by coronary angiogra-
phy.
In normal coronary arteries without an epicardial flow-
limiting stenosis, CVFR is controlled by the microcircula-
tory resistances, and coronary hyperemia can be induced
by vasodilatory drugs and physiologic stimuli decreasing
the resistances of microcirculation. Hemodynamic signif-
icant epicardial coronary stenoses create strong proximal
resistances that are higher than that opposed from the
microcirculation, and reduce the CVFR [8]. Several recent
reports have documented the feasibitity of transthoracic
echocardiography (with the pulsed Doppler sample vol-
ume placed distally to the flow-limiting stenosis) of esti-
mating the CVFR [2-4,8]. A CFVR value of less than 2 has
been widely adopted to indicate one or more hemody-
namic significant stenoses located more proximally in the
coronary artery [8], documented for the LAD [4] and RDP
[3]. Our patient showed pathologic CVFR of the RDP
(Table 1, Figure 2) and normal CVFR of the LAD (Table 1),
confirming the findings of a significant stenosis in the
RCA and an open LAD.
With the use of transthoracic echocardiography, both
direct visualization of formerly angioplasty-treated seg-
ments [9] and CVFR measurements [10] have been
reported as suitable methods of follow-up of treated sten-
oses. After a successful PCI treatment of the stenosis in the
mid RCA, our patient presented with chest pain suggestive
of possible restenosis. However, both direct visualization
of this segment and CVFR measurement of the RDP (Table
1, Figure 5) indicated normal flow in the RCA as was con-
firmed by coronary angiography.
Conclusion
This case illustrates the value of transthoracic echocardi-
ography as a tool both in the diagnosis and the follow-up
of chest pain disorders and coronary flow problems. Tran-
sthoracic echocardiography allows both direct visualiza-
tion of the various coronary segments and assessment of
the CVFR of the LAD and RCA. With the use of these tech-
niques, we were able to correctly identify a hemodynamic
significant stenosis of the mid RCA. When the patient was
readmitted with chest pain we could exclude flow limita-
tion in the stented segment by transthoracic ultrasound
examination of the RCA.
Angiography shows the stenosis of RCAFigure 3
Angiography shows the stenosis of RCA.
Angiography shows RCA after PCIFigure 4
Angiography shows RCA after PCI.Page 4 of 5
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Direct visualization of a significant stenosis of the right coronary artery by transthoracic echocardiography. A case report

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