PMC4008445_01
Transthoracic colour-flow Doppler echocardiography. (a) Four-chamber view. (b) Parasternal short axis view. Both images show multiple collateral vessels within the IV septum and abnormal signals in the coronary arteries, indicating dilatation and tortuosity. RA: right atrium; LA: left atrium; LV: left ventricle; RV: right ventricle; RVO: right ventricle outflow; LVO: left ventricle outflow; IV: interventricular.
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fig1
TTE was remarkable for very unusual colour Doppler signals in the right ventricle (Figures 1(a) and 1(b)). There was a prominent pattern of diastolic flow within the right ventricular myocardium, especially along the interventricular septum.
(a) Coronary angiogram. The catheter is in the aorta and the left main is engaged. Collateral vessels from the LCA deliver contrast media into the RCA, which subsequently drains into the main PA. (b) MRI velocity flow map. Coded black is flow down the LCA away from the aorta. Coded white is flow up the RCA towards the main PA. PA: pulmonary artery; RCA: right coronary artery; LCA: left coronary artery.
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fig2
The pattern of blood flow was from the aortic sinus of Valsalva into the LCA, which then filled the right coronary artery (RCA) through collateral epicardial vessels; flow then passed into the pulmonary artery (PA) in a retrograde manner (Figure 2(a)). Cardiac magnetic resonance (CMR) (Figure 2(b)) was subsequently undertaken to enable flow study calculation; the flow from the RCA into PA occurred at an elevated rate of 1.3 L/min, which represented almost a quarter of her cardiac output.
(a) Three-dimensional rendering of CT angiogram demonstrating ARCAPA. The right coronary artery originates from the anterior, lateral aspect of the pulmonary artery approximately 8 mm above the pulmonary valve. (b) intraoperative images of ARCAPA, prior to surgical correction. PA: pulmonary artery; RCA: right coronary artery; LCA: left coronary artery.
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fig3
To enable more specific anatomical localization of the coronary circulation and heart structure, multislice computed tomography (MSCT) (Figure 3(a)) was performed. In the operating room, the exposed course of the anomalous right coronary artery was exactly as predicted by imaging (Figure 3(b)).