Coronary arterial anatomy in tetralogy of Fallot: morphological and clinical correlations

Abstract

Objective-To clarify the problems in angiographic diagnosis of major coronary arteries crossing the right ventricular outflow tract. Design-Aretrospectivestudywithclinicomorphological correlations to ascertain any aberrant coronary arteries and variations in distribution of the normal right coronary arterial branches. Setting-Tertiary referral centre. Subjects-36 necropsy specimens together with the aortograms and surgical reports from 130 patients with tetralogy of Fallot. Results-A preventricular branch was found in 19% of cases with tetralogy of Fallot, but in none of 13 normal hearts. Aberrant origin of the anterior interventricular coronary artery was found in 14% of the specimens. The combination of "laid back" and straight lateral views, when reviewed retrospectively, identified this anomaly correctly in nine of 16 patients, with these findings confirmed at surgery in seven patients. A major branch initially thought to cross the outflow tract was shown retrospectively to be an infundibular artery in six, with surgical confirmation in four. It was a preventricular branch in another patient. Conclusions-Using the laid back view alone, infundibular and preventricular branches may be mistaken for a major aberrant artery. A combination of laid back and straight lateral views is needed to avoid false positive diagnosis. (Heart 1998;80:174-183) Keywords: angiography; congenital heart defects; tetralogy of Fallot; paediatric cardiologyThe incidence of a major coronary artery crossing the right ventricular outflow tract in tetralogy of Fallot is between 5% and 12%. [1][2][3][4][5][6][7] Such an anomalous vessel is not always detectable intraoperatively. 3 Preoperative recognition of such arteries is therefore crucial in deciding the time and type of operative procedure to be performed. Despite advances in echocardiographic assessment, investigation by angiography is still considered important in evaluating the coronary arterial patterns preoperatively. The sensitivity and specificity of such angiography, however, remains uncertain. Aortography in standard and oblique projections often fails to identify the origins of the coronary arteries and, more importantly, fails to reveal their relation to the right ventricular outflow tract. More recently, the caudo-cranial left anterior oblique (so called "laid back") aortograms have been advocated for identifying abnormal vessels that cross the pulmonary outflow tract.8 9 In reviewing the experience at our hospital over five years, we have found evidence of one false negative and several false positive diagnoses using the laid back view. These patients with false positive angiographic diagnoses were found, at surgery, to have prominent infundibular or preventricular branches of the right coronary artery rather than anomalous origin of the anterior interventricular (anterior descending) branch of the left coronary artery. These diYculties prompted us to reinvestigate the anatomy of the coronary arteries in tetralogy of Fallot, comparing our findings with the vari...

Clinical indications for cardiovascular magnetic resonance (CMR): Consensus Panel report?

“…CMR is useful in defining congenital or inflammatory changes of the coronary arteries as in Bland-White-Garland syndrome, 62 and Kawasaki disease. [63][64][65] Congenital abnormalities in the course of the proximal coronary arteries can be reliably depicted by CMR both in patients with CHD (prevalence of 30% in CHD), 66 and especially tetralogy of Fallot, 67,68 and also in those with otherwise normal cardiac anatomy (1% of the general population). [69][70][71] CMR has advantages over X-ray angiography in clarifying the spatial relationship of these arteries with respect to the aorta and the pulmonary artery, which is crucial for estimating the risk associated with these abnormalities and for surgical planning.…”

MDCT evaluation of the right ventricle–pulmonary artery bypass stenosis in corrected tetralogy of Fallot

“…Although magnetic resonance imaging has been recognized as well suited to assess the detailed cardiac anatomy in postoperative patients with TOF, it has not been possible until recently to evaluate the three-dimensional anatomy of the whole heart and great vessels [3]. In addition, magnetic resonance imaging is not feasible for detecting anomalous coronary artery which frequently accompanies TOF [4] because of its limited spatial resolution. MDCT permits direct visualization of the whole coronary artery system with its high spatial resolution.…”

A Rare Case of Congenitally Corrected Transposition of Great Arteries with Complete Heart Block

“…11 Our review of literature focusing on the coronary arterial anatomy in CCTGA has demonstrated that some patients had significant coronary abnormalities, [13][14][15] but interestingly this was less frequently than what has been observed in other common congenital cardiac lesions. [16][17][18][19] It is important to know of the presence of a coronary anomaly (in origin, course and distribution) in order to determine the optimal surgical approach and outcome. 11 Previous studies have suggested a consistently inverted coronary arterial pattern in patient with CCTGA and, rarely, a coronary ostium or artery.…”