European Journal of Echocardiography 2005 6(4):308-310; doi:10.1016/j.euje.2004.11.006
Copyright © 2004, The European Society of Cardiology
Failure of multiple coronary angiographies to identify left main coronary artery disease in a patient diagnosed by transesophageal echocardiography
Saeed A.L. Ahmari*,
Asim Idris,
Hussin A.L. Amri and
Moh'd Habbab
Department of Adult Cardiology, Prince Sultan Cardiac Center, PO. Box 340301, Riyadh 11333, Saudi Arabia
Received 20 September 2004; received in revised form 8 November 2004; accepted after revision 22 November 2004.
* Corresponding author. Tel.: +966 4777714x8840; fax: +966 4778771.
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Abstract
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This case report describes the role of transesophageal echocardiography
to diagnose proximal left main coronary artery disease.
Keywords: Coronary; Echocardiography; Angiography
We report a patient with classical angina pectoris with significant
proximal left main coronary artery (LMCA) disease, suggested
by coronary angiogram and confirmed by transesophageal echocardiography
(TEE). The report discusses the role of TEE in the diagnosis
of LMCA disease.
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Case report
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A 67-year-old male presented with two weeks history of progressive
anginal pain. On presentation he had class III angina. He is
not known to have diabetes mellitus, hypertension or hyperlipidemia.
Cardiac catheterization done in 1998, and 2001 only revealed
mild (30%) right coronary artery (RCA) disease. During the course
of his disease, a stress test was not performed. Physical examination
including cardiovascular examination was normal. Twelve-lead
electrocardiograms (ECG) revealed dynamic ST segment elevation
of 1–2mm in lead V2–lead V6. Multiple sets of cardiac
enzymes, 8h apart, were normal and troponin test was negative.
The echocardiogram showed normal left ventricle systolic function
with no regional wall motion abnormality and normal valves.
During coronary angiogram and upon engagement of the LMCA there
was damping of blood pressure from 140 to 60mmHg. A significant
LMCA disease was suspected but could not be confirmed by coronary
sinus injection (
Fig. 1). The rest of the coronary arteries
were normal except for a 60% stenosis in the mid right coronary
artery (RCA). Due to the damping of pressure, intravascular
coronary ultrasound (IVUS) was not safe to further evaluate
the LMCA disease and transesophageal echocardiogram (TEE) was
performed. The mid esophageal transverse view, at the base of
the heart and at the level of the left sinus of Valsalva, visualized
the entire length of the LMCA. A proximal concentric atheroma
with 60% luminal diameter stenosis was found. Color Doppler
imaging showed flow turbulence at the site of stenosis (
Fig. 2)
and the pulsed Doppler revealed a diastolic flow velocity of
88cm/s (
Fig. 3A). Further distal imaging showed the LM bifurcation,
proximal left anterior descending (LAD) and left circumflex
(LCx) coronary arteries to be free of the disease. The diastolic
coronary velocity in the LAD was 44cm/s (
Fig. 3B). Accordingly
the patient had coronary artery bypass surgery with left anterior
mammary to the LAD and two saphenous vein grafts to RCA and
LCx coronary arteries. The patient became asymptomatic in the
immediate postoperative course as well as at 6 months later
in the clinic follow-up.
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Figure 1 Left sinus of Valsalva angiograms, in the left anterior oblique (A) and right anterior oblique (B), both with cranial angulations, failed to demonstrate the presence of significant left main coronary artery disease.
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Figure 2 Transesophageal echo view at the level of the sinus of Valsalva with color Doppler imaging of the left main coronary artery (LMCA), demonstrating a significant concentric atheroma and color flow turbulence in the proximal LMCA (arrow head). LA: left atrium, LAA: left atrial appendage.
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Figure 3 Pulse Doppler sampling of the left main coronary artery (LMCA) flow (A) and of the proximal left anterior descending (LAD) flow (B) showing the characteristic systolic and diastolic coronary flow. The LMCA peak diastolic velocity is increased as compared to diastolic velocity in the LAD, indicating the presence of significant flow limiting lesion.
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Discussion
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Visualization of the coronary arteries has been one of the challenging
tasks for echocardiography. Weyman was the first to describe
the feasibility of visualizing the LMCA with transthoracic echocardiography.
1 Other studies demonstrated the ability of detecting the distal
left anterior descending coronary artery using high frequency
transducer (7.5MHz) in 85% of patients.
2 TEE has been used successfully
in assessing the proximal coronary arteries, identifying anomalous
coronary arteries, and coronary fistulae.
3 In a study of 160
patients who underwent both TEE and coronary angiography, the
entire proximal left coronary artery was identified in 70% of
patients. The sensitivity and specificity of TEE in identifying
stenosis of the LMCA, proximal LAD, and proximal LCx arteries
were 100% and 98%, 79% and 89%, 54% and 84%, respectively.
4 Recording the flow with pulsed-wave Doppler was feasible in
88% of studies for the LMCA, 85% for the LAD, 58% for the left
circumflex, and 65% for the RCA.
5 In a comparative study of
94 patients, a high correlation was found between the results
of TEE and quantitative coronary angiography for the LMCA, LAD,
LCx and RCA.
6 Also, a good linear correlation was found between
TEE derived luminal percent area stenosis, using a modified
continuity equation, and quantitative angiography.
6 In addition,
three dimensional transesophageal echocardiography was found
to be successful in delineating normal and stenotic proximal
coronary arteries.
7,8 The LMCA, LAD, LCx and RCA were visualized
in 100%, 100%, 98%, and 72% of the patients, respectively, with
a sensitivity and specificity in detecting significant stenosis
of 84% and 97%.
8
Our patient presented with typical anginal chest pain with minimal exertion suggesting significant coronary artery disease. The only clue to the presence of proximal LMCA disease was the pressure damping with LMCA engagement. Multiple angiographic views did not delineate the presence of significant LM coronary artery disease. The TEE was considered safer than IVUS, because of the pressure damping during cardiac catheterization. In this case, the entire length of the LM, and the proximal luminal stenosis was demonstrated clearly by TEE. The bifurcation and proximal LAD, and LCx arteries were also visualized and were free of disease. The color Doppler imaging further localized the site and extent of stenosis which was depicted as aliasing and turbulence of color flow. The pulse Doppler showed the increase in peak diastolic velocity in LM compared to diastolic velocity in the LAD, indicating the presence of significant flow limiting lesion. The normal coronary flow in the left system consists of small systolic and large diastolic components as shown in Fig. 3. This flow pattern is due to the presence of a gradient between the aorta and the coronary vessels in diastole as compared to systole. This case demonstrates clearly the usefulness of TEE in estimating the severity of LMCA disease especially when IVUS cannot be performed.
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References
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- Weyman A.E., Feigenbaum H., Dillon J.C., Jhonston K.W., Eggleton R.C. Noninvasive visualization of the left main coronary artery by cross-sectional echocardiography. Circulation (1976) 54:169–174.[Abstract/Free Full Text]
- Ross J.J. Jr., Mintz G.S., Chandrasekaran K. Transthoracic two-dimensional high frequency (7.5MHz) ultrasonic visualization of the distal left anterior descending coronary artery. Journal of the American College of Cardiology (1990) 15:373–377.[Abstract]
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- Yao J., Taams M.A., Kasprzak J.D., de Feijter P.J., ten Cate F.J., Van Herwerden L.A., et al. Usefulness of three-dimensional transesophageal echocardiographic imaging for evaluating narrowing in the coronary arteries. American Journal of Cardiology (1999) 84:41–45.[CrossRef][Web of Science][Medline]
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Abstract
Case report