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CARDIOVASCULAR ANESTHESIA

Intraoperative Transesophageal Echocardiographic Visualization of a Left Anterior Descending Coronary Artery Aneurysm

From the Divisions of Cardiac Anesthesia and Cardiac Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts.

Address correspondence and reprint requests to Adam B. Lerner, MD, BIDMC, Department of Anesthesia, CC470, 1 Deaconess Road, Boston, MA 02215. Address e-mail to alerner{at}bidmc.harvard.edu.

A 76-yr-old man presented for elective coronary artery bypass grafting. Coronary angiography performed after a positive exercise stress test had revealed an 80% stenosis of the left main coronary artery. An aneurysm of the proximal left anterior descending (LAD) coronary artery, approximately 1.5 cm in diameter, was also noted (Fig. 1). Intraoperative transesophageal echocardiography (TEE), performed after the induction of anesthesia, demonstrated this aneurysm as a 1.3-cm echolucency in the basal anterior wall of the left ventricle, just medial to the left atrial appendage (Fig. 2a). Color Doppler mapping of this echolucency demonstrated blood flow confined to diastole (Fig. 2b). Further TEE imaging demonstrated this echolucency to be contiguous with the left main coronary artery segment (please see video clip available at www.anesthesia-analgesia.org). After sternotomy and pericardiotomy, palpation by the surgeon confirmed the location of the aneurysm between the left atrial appendage and pulmonary artery. The patient underwent successful three-vessel coronary artery bypass grafting, including bypass of the LAD, obtuse marginal branch of the left circumflex artery, and the ramus intermedius branch. After palpation and evaluation by the surgical team, it was decided that surgical resection of the aneurysm was not prudent because of its anatomy and location.

View larger version (165K): [in this window] [in a new window]   Figure 1. Right anterior oblique cranial image with angiography of the left coronary circulation showing stenosis of distal left main coronary artery and large proximal LAD aneurysm. LAD, left anterior descending coronary artery.

View larger version (45K): [in this window] [in a new window]   Figure 2. Intraoperative transesophageal echocardiography (TEE) images from the midesophageal position. (a) A 1.3-cm LAD aneurysm can be seen just medial to the left atrial appendage. (b) Color Doppler imaging of the aneurysm reveals diastolic blood flow. LAD, left anterior descending coronary artery; LA, left atrium; LAA, left atrial appendage.

Coronary artery aneurysms occur at a reported incidence of 1%–5% in patients with coronary atherosclerosis undergoing angiography (1). Angiographically, they are defined as a dilation of the coronary artery 1.5 times larger than that of a normal adjacent segment. Etiologies in adults include arteritis, connective tissue disorders, and iatrogenic causes related to percutaneous coronary procedures. Prognosis and management of this condition are not clearly defined. Possible interventions may include placement of coils within the lumen of the aneurysm or placement of a coronary stent across the ostium of the aneurysm to exclude it from blood flow. In our case, the differential diagnosis for an echolucency in the observed location includes pericardial cyst, loculated pericardial effusion, enlarged coronary sinus, and other coronary arterial pathology, including coronary arteriovenous fistula. However, preoperative angiography had already alerted us to the presence of this pathology.

Evaluation of coronary arteries by TEE can be challenging because of the size and location of these vessels. The left and right main coronary arteries and the proximal segments of the LAD and left circumflex arteries can be visualized during intraoperative TEE in most patients (2). The proximal left main and right coronary (RCA) artery segments can be most easily visualized in the midesophageal (ME), aortic valve, short axis view which generally requires an omniplane angle between 40° and 60°. Gradual reduction of the omniplane angle towards 0° from this view allows for visualization of the entire left main segment to the level of its bifurcation. The LAD can be seen from this point coursing towards the ventricular apex, while the left circumflex artery is directed into the atrioventricular (AV) groove. Other ME images of the AV groove, such as the two-chamber view, allow visualization of more distal segments of the left circumflex artery, usually in the short axis. Anterior flexion of the TEE probe while in the short axis view of the aortic valve allows for visualization of the RCA directed downward and into the right AV groove. The proximal RCA can also be seen in the ME, aortic valve, long axis view at an omniplane angle generally between 120° and 140°. Further evaluation and delineation of the coronary arteries include both color and either pulse or continuous wave Doppler interrogation. Doppler evaluation by any of these modalities should demonstrate a biphasic blood flow pattern with a diastolic predominance. Normal blood velocity profiles measured in different coronary artery segments by pulse wave Doppler have been published (3) and comparison with these values may also help to characterize whether an identified structure is consistent with a coronary artery. Epicardial echocardiographic evaluation of the coronary arteries using high-frequency (10–12 MHz) probes has also been described (4), and when available, may serve as a useful modality in situations where TEE does not allow for adequate visualization.

	Footnotes

 
This article has supplementary material on the Web site: www.anesthesia-analgesia.org.

Accepted for publication October 26, 2006.

	REFERENCES

Top REFERENCES

 

1. Manginas A, Cokkinos DV. Coronary artery ectasias: imaging, functional assessment and clinical implications. Eur Heart J 2006;27:1026–31.[Abstract/Free Full Text]
2. Youn HJ, Foster E. Transesophageal echocardiography (TEE) in the evaluation of the coronary arteries. Cardiol Clin 2000;18:833–48.[Medline]
3. Kasprzak JD, Drozdz J, Peruga JZ, et al. Definition of flow parameters in proximal nonstenotic coronary arteries using transesophageal Doppler echocardiography. Echocardiography 2000;17:141–50.[Web of Science][Medline]
4. Sahn DJ, Barratt-Boyes BG, Graham K, et al. Ultrasonic imaging of the coronary arteries in open-chest humans: evaluation of coronary atherosclerotic lesions during cardiac surgery. Circulation 1982;66:1034–44.[Abstract/Free Full Text]

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This Article Full Text (PDF) Echo Loop Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Karthik, S. Articles by Lerner, A. B. Search for Related Content PubMed PubMed Citation Articles by Karthik, S. Articles by Lerner, A. B. Related Collections Cardiovascular Echo Rounds Video Clip