Circumflex Origin from Right Coronary Artery—The Anomaly That Should Not Be Omitted during Echocardiography—”Crossed Aorta” and “Bleb Sign” Presentation after Stents Implantation

Abstract

Mini‐Abstract Simultaneously with the development of echocardiography its potential in the assessment of coronary arteries increases. We reported previously that the anomalous circumflex (Cx) originating from right coronary artery (RCA) with retroaortic course may be observed in transesophageal examination (TEE) as vessel cross section in the mitroaortic angle—”bleb sign” or visualized in modified apical four‐chamber view behind left atrium during transthoracic study (TTE). In present case, we propose novel finding indicating on this anomaly in apical five‐chamber view in TTE forming “crossed aorta” sign. Additionally, the presence of stents in Cx enhanced echocardiographic presentation of anomalous artery course.

Detection of the “Crossed Aorta Sign” during Echocardiography before Angiography

“…Usually, the diagnosis of this congenital anomaly of coronary circulation is established during coronary angiography, and stent implantation generally facilitates an echocardiographic view of the vessel course. In our case, the diagnosis was performed by echocardiography, before angiography, detecting “crossed aorta sign” [ 3 ], a novel echocardiographic sign, in an apical five-chamber view in which Cx seemed to cross the aorta perpendicularly to aortic long axis. At echocardiographic exam, the “crossed aorta sign” can be confused with the course of the coronary sinus.…”

“…This is due to the fact that implanted stents make the anomalous Cx hyperechogenic and easier to be noticed at echocardiography. Our case is particular, since Cx coursing detection was found before stent implantation [ 3 ]. In our case, the diagnosis was performed by echocardiography, before angiography, detecting “crossed aorta sign” [ 3 ], a novel echocardiographic sign, in an apical five-chamber view in which Cx seemed to cross the aorta perpendicularly to aortic long axis.…”

“…Our case is particular, since Cx coursing detection was found before stent implantation [ 3 ]. In our case, the diagnosis was performed by echocardiography, before angiography, detecting “crossed aorta sign” [ 3 ], a novel echocardiographic sign, in an apical five-chamber view in which Cx seemed to cross the aorta perpendicularly to aortic long axis. We believe that the development of echocardiographic technologies will increase the potential role of echo also in the diagnosis of coronary artery anomalies and other pathological entities that were previously misdiagnosed.…”

“…The transthoracic echocardiogram (TTE) revealed a normal left ventricle (LV) ejection fraction (55%), with limited apical wall motion abnormality. Furthermore, on the basis of a “crossed aorta sign,” we suspected the anomalous circumflex (Cx) coronary artery with probable origin from the right sinus of Valsalva ( Figure 1 ) [ 3 ]. In a five-chamber apical view, Cx seemed to cross the aorta perpendicularly to aortic long axis, suggesting retroaortic course (Figures 2(a) and 2(b) ), as previously described by Wierzbowska and colleagues.…”

“…This is a new type of echocardiographic sign, which can help to detect the retroaortic coursing of Cx. In our case, the use of the TEE technic was not necessary, since the abnormal course of the Cx was already well detectable by transthoracic echocardiography [ 3 ]. During angiography, the anomalous Cx origin from the right sinus was confirmed (Figures 3(a) and 3(b) ).…”