From “not well seen” to “likely normal”: Basic echocardiographic imaging of the coronary arteries in pediatric patients for diagnosis of anomalous aortic origin

Transthoracic echocardiography is the initial imaging modality used to screen for congenital coronary anomalies in the pediatric population. Successful imaging of the coronary arteries depends on multiple factors including imaging technique, patient body habitus, acoustic imaging window availability, and patient cooperation. A standardized transthoracic imaging protocol performed by an experienced echocardiographer has been shown to improve detection rates of anomalous aortic origin of the coronary artery. This paper reviews basic transthoracic echocardiographic assessment of the coronary arteries and techniques for image optimization. A thorough evaluation includes determining the originating sinus, proximal course, visualization of flow within the coronary arteries, and assessment of flow with color Doppler. Cine clips of two-dimensional and color Doppler imaging should be recorded. Our institution prefers using the color compare feature of the equipment and color cine images. Still frame images of the coronary arteries are not recommended since false dropout may cause an anomalous coronary artery to appear normal. We recommend interrogating the inter-arterial space between the aorta and the pulmonary artery in parasternal short-axis view with low velocity color Doppler to identify linear diastolic color flow pattern within the aortic wall. Acute angle takeoff in addition to the color flow within proximal coronary lumen can be used to make the diagnosis of a proximal intramural course of anomalous coronary artery. Imaging should also focus on demonstrating ostial origin from the aortic sinus and branching of the left coronary artery into left circumflex artery and left descending artery.