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Echocardiographic assessment of coronary circulation

Non-invasive Imaging: Echocardiography


In the first presentation, A. Hagendorff illustrated the possibilities of transthoracic and transesophageal echocardiography to visualize native coronary arteries as well as coronary artery flow. The morphological analysis of coronary arteries in distinct portions of the vessels is possible in 2D and multidimensional echocardiography, e.g. the proximal part of the left anterior descending artery (LAD) as well as of the right coronary artery.
Multidimensional images of the first 6cm of the right coronary artery or the view into the ostium of the right coronary artery with frame rates between 20 and 100/sec were shown. The colour-coded signals of portions of the coronary artery tree of all three main territories were documented, including functional analysis by Doppler/spectra. Also the multidimensional imaging of the colour/coded flow signals were presented.
The next presentation by F. Rigo (Mestre-Venice, IT) illustrated the prognostic impact of coronary flow reserve (CFR) in patients with coronary heart disease, as well as microvessel disease. The combination of wall motion assessment and flow reserve determination – especially in assumed LAD-problems – should be incorporated into our clinical routine. Thus, determination of coronary flow reserve has to be established in the clinical scenario throughout Europe. Nevertheless, the predominant region for CFR determination is the LAD territory, because the right coronary artery and the circumflex branch are often not detectable on transthoracic echocardiography.

R. Senior (London, GB) reported about myocardial flow reserve determination by myocardial contrast imaging. Besides the fact that the detection of subendocardial hypoperfusion is well visible in real time myocardial contrast imaging just by visual analysis, the quantification of myocardial blood volume and blood flow using the replenishment analysis enables the calculation of the myocardial flow reserve in all myocardial territories, especially in the circumflex territory. In addition, contrast echocardiography makes it possible to detect capillary recruitment during stress. Thus, the differentiation of hypertrophy due to cardiomyopathy from athlete’s heart is possible using contrast.

The last presentation by B. Herzog (Leeds, UK) illustrated the imaging potentials of cardiac computed tomography (CT) for coronary imaging, as well as the functional approach of cardiac imaging in cardiac CT. In direct visualisation of coronary arteries, CT provides accurate and excellent images with lower x-ray exposition than previously used. Thus, the x-ray exposition with the newest scanners and techniques is between 1 and 2 mSV. However, for functional analysis with cardiac CT, the x-ray exposition is more than 20 mSV. Therefore, functional analysis of the heart should be performed by other imaging modalities like echocardiography and cardiac MR. We should keep in mind that according to the calculations of Brenner and Hall, an x-ray exposition of 4-6 mSV in a patient younger than 35 years increases the individual risk of cancer about 3-4 fold.

Conclusion:

In summary, the session documented the multiple imaging modalities of coronary arteries and coronary artery flow. However, echocardiography should be the first choice of the diagnostic procedure – even if the target is the direct visualisation of the coronary vessels.

References


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Echocardiographic assessment of coronary circulation

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.

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