Sensitivity and Specificity of Transthoracic Echocardiography in Diagnosing the Presence of the Anomalous Origin of Left Circumflex Coronary Artery From the Right Sinus of Valsalva in an Adult Population (vol 12, e030173, 2023)

HomeJournal of the American Heart AssociationAhead of PrintSensitivity and Specificity of Transthoracic Echocardiography in Diagnosing the Presence of the Anomalous Origin of Left Circumflex Coronary Artery From the Right Sinus of Valsalva in an Adult Population Open AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citations ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toOpen AccessLetterPDF/EPUBSensitivity and Specificity of Transthoracic Echocardiography in Diagnosing the Presence of the Anomalous Origin of Left Circumflex Coronary Artery From the Right Sinus of Valsalva in an Adult Population Stefano Bonapace, Laura Lanzoni, Andrea Rossi, Carmelo Cicciò, Mariantonietta Cicoira, Clementina Dugo, Caterina Maffeis, Filippo Valbusa, Guido Canali, Massimo Guerriero and Giulio Molon Stefano BonapaceStefano Bonapace *Correspondence to: Stefano Bonapace, MD, Division of Cardiology, Istituto di Ricovero e Cura a Carattere Scientifico Sacro Cuore–Don Calabria, via Don Sempreboni 5, 37024 Negrar, Italy. Email: E-mail Address: [email protected] https://orcid.org/0000-0001-9122-2642 , Division of Cardiology, , Istituto di Ricovero e Cura a Carattere Scientifico Sacro Cuore–Don Calabria, , Negrar, , Italy, Search for more papers by this author , Laura LanzoniLaura Lanzoni , Division of Cardiology, , Istituto di Ricovero e Cura a Carattere Scientifico Sacro Cuore–Don Calabria, , Negrar, , Italy, Search for more papers by this author , Andrea RossiAndrea Rossi https://orcid.org/0000-0001-7095-7121 , Division of Cardiology, Department of Medicine, , University of Verona, , Verona, , Italy, Search for more papers by this author , Carmelo CicciòCarmelo Cicciò https://orcid.org/0000-0001-9769-8043 , Division of Radiology, Department of Imaging, , Istituto di Ricovero e Cura a Carattere Scientifico Sacro Cuore–Don Calabria, , Negrar, , Italy, Search for more papers by this author , Mariantonietta CicoiraMariantonietta Cicoira , Division of Cardiolgy, , Ospedale Magalini, , Villafranca, , Italy, Search for more papers by this author , Clementina DugoClementina Dugo https://orcid.org/0000-0002-1457-4975 , Division of Cardiology, , Istituto di Ricovero e Cura a Carattere Scientifico Sacro Cuore–Don Calabria, , Negrar, , Italy, Search for more papers by this author , Caterina MaffeisCaterina Maffeis , Division of Cardiology, Department of Medicine, , University of Verona, , Verona, , Italy, Search for more papers by this author , Filippo ValbusaFilippo Valbusa https://orcid.org/0000-0001-7527-6974 , Division of Internal Medicine, , Istituto di Ricovero e Cura a Carattere Scientifico Sacro Cuore–Don Calabria, , Negrar, , Italy, Search for more papers by this author , Guido CanaliGuido Canali , Division of Cardiology, , Istituto di Ricovero e Cura a Carattere Scientifico Sacro Cuore–Don Calabria, , Negrar, , Italy, Search for more papers by this author , Massimo GuerrieroMassimo Guerriero https://orcid.org/0000-0003-1310-539X , Clinical Research Unit, , Istituto di Ricovero e Cura a Carattere Scientifico Sacro Cuore–Don Calabria, , Negrar, , Italy, Search for more papers by this author and Giulio MolonGiulio Molon , Division of Cardiology, , Istituto di Ricovero e Cura a Carattere Scientifico Sacro Cuore–Don Calabria, , Negrar, , Italy, Search for more papers by this author Originally published29 Jun 2023https://doi.org/10.1161/JAHA.123.030173Journal of the American Heart Association. 2023;0:e030173Anomalous coronary artery (ACA) origin affects around 0.6% to 1.2% of the general population without other congenital heart disease.1 A multimodality imaging approach is usually necessary to correctly assess the origin and proximal course of ACA, and transthoracic echocardiography (TTE) represents the first step in this diagnostic process, followed by coronary computed tomography.1 The anomalous origin of the left circumflex coronary artery (aLCX) from the right coronary sinus, first described by Antopol and Kugel2 in 1933, is the most common ACA, with a prevalence at coronary angiography of 0.18% to 0.67%; 3 different variants are described3: type I with separated ostia between right coronary artery and aLCX (Figure [A]), type II with a common ostium between right coronary artery and aLCX (Figure [B]), and type III with aLCX arising as a proximal branch of right coronary artery with a short common trunk (Figure [C]). Although it is considered a “benign” variant,3 its recognition is useful to avoid its damage during aortic and mitral valve surgical replacement.4 The aim of this observational prospective study was to evaluate the sensitivity and specificity of a TTE sign of a “double binary tubular image” (DBTI; Figure [D–F]), observed above the mitral annular plane and crossing the aorta in apical projections, in predicting the presence of aLCX,5 in all consecutive adult patients (aged >18 years) who underwent TTE before clinically indicated elective coronary angiography between January 2016 and October 2021 at our institution. Angiographic calcifications and the reference vessel diameter with quantitative coronary analysis of aLCX in its retroaortic segment were also assessed. The study protocol was approved by the Ethics Committee of Verona and Rovigo (protocol number 11 568), and all patients provided informed consent. The data of the study may be available from the corresponding author on request. Data are presented as mean±SD or percentage. Unpaired Student t test was used to test differences between continuous variables. Sensitivity was calculated as [true positive (TP)/TP+false negative (FN)]×100, specificity as [true negative (TN)/false positive (FP)+TN]×100, positive predictive value as [TP/TP+FP]×100, negative predictive value as [TN/TN+FN]×100, and the diagnostic accuracy as [TP+TN/TP+TN+FP+FN]×100. A total of 4045 patients, aged 69.9±11.3 years, 72.1% men, were studied. A total of 47 (1.16%) ACA origins were found at coronary angiography, among them 24 (0.59%) had aLCX, 6 (25%) type I, 9 (37.5%) type II, and 9 (37.5%) type III. The mean age of patients with aLCX was 66.1±11.4 years, ranging between 41 and 80 years, and 75% were men. Furthermore, we found 8 (0.19%) anomalous origin of right coronary artery (6 with high take off from the ascending aorta, and 2 originating from the left coronary sinus), 12 (0.29%) absence of left main trunk with split left anterior descending artery and left circumflex coronary artery origin at left coronary sinus, 2 (0.05%) anomalous origin of left anterior descending artery at the right coronary sinus, and 1 (0.02%) single coronary artery arising from right coronary sinus. The DBTI was present in 22 patients at TTE. In 20 of them, the diagnosis was confirmed by coronary angiography; 4 FN and 2 FP subjects were found (Figure [G]).Download figureDownload PowerPointFigure 1. Angiographic appearance of type I, II, and III anomalous origin of the left circumflex coronary artery (aLCX) (A–C; white arrows), the double binary tubular image (DBTI) at transthoracic echocardiography (TTE) in apical 4‐, 5‐, and 2‐chamber views (D–F; white arrows), and the numbers of patients cross‐classified by diagnosis (G).The sensitivity, specificity, positive predictive value, and negative predictive value of this TTE sign were 83.3% (95% CI, –068.4%–98.2%), 99.9% (95% CI, –99.8%–100%), 90.9% (95% CI, –78.9%–102.9%), and 99.9% (95% CI, –99.8%–99.9%), respectively, with a diagnostic accuracy of 99.8%. Among those patients with the DBTI sign, 41.6% had no angiographic calcifications and 58.4% had various degrees of angiographic calcifications. Mild angiographic calcifications were present in 75% among those in whom the DBTI was not identified. There was a significant difference in aLCX retroaortic diameter among those with DBTI compared with those without DBTI (2.53±0.2 versus 1.44±0.14 mm; P<0.0001).This is the first report evaluating the diagnostic accuracy of this TTE sign in predicting the presence of aLCX. Different from other ACA origins in aLCX, TTE was unable to detect the anomalous position of the coronary ostium but allowed us to highlight the retroaortic course of the artery in proceeding from its origin to reach the normal location at the level of the atrioventricular groove.5 This anomalous pathway probably exposes the vessel wall to a more favorable incident ultrasound beam angle (ie, more perpendicular), allowing the best visualization of aLCX during its course rather than at its origin.5 The retroaortic diameter of aLCX rather than its degree of calcifications seems to be the most relevant factor allowing its detection.The main limitation of the study is related to the small number of aLCX, which widens the CI around the estimate of sensitivity, reducing its precision.In conclusion, this study shows, for the first time, that TTE has a high diagnostic accuracy to identify the aLCX in an adult population. The recognition of this DBTI sign at TTE allows us to avoid more invasive and expensive investigations, such as coronary computed tomography scan, for this specific coronary anomaly.Sources of FundingNone.DisclosuresNone.Footnotes*Correspondence to: Stefano Bonapace, MD, Division of Cardiology, Istituto di Ricovero e Cura a Carattere Scientifico Sacro Cuore–Don Calabria, via Don Sempreboni 5, 37024 Negrar, Italy. Email: stefano.[email protected]itThis article was sent to Erik B. Schelbert, MD, MS, Associate Editor, for review by expert referees, editorial decision, and final disposition.For Sources of Funding and Disclosures, see page 3.References1 Angelini P. Coronary artery anomalies. An entity in search of an identity. Circulation. 2007; 10:1296–1305. doi: 10.1161/CIRCULATIONAHA.106.618082LinkGoogle Scholar2 Antopol W, Kugel MA. Anomalous origin of the left circumflex artery. Am Heart J. 1933; 8:802–806. doi: 10.1016/S0002-8703(33)90141-6CrossrefGoogle Scholar3 Page HL, Engel HJ, Campbell WB, Thomas CS. Anomalous origin of the left circumflex coronary artery: recognition, angiographic demonstration and clinical significance. Circulation. 1974; 50:768–773. doi: 10.1161/01.CIR.50.4.768LinkGoogle Scholar4 Vaishnava P, Pyo R, Filsoufi F, Sharma S. Compression of an anomalous left circumflex artery after aortic and mitral valve replacement. Ann Thorac Surg. 2011; 92:1887–1889. doi: 10.1016/j.athoracsur.2011.04.095CrossrefMedlineGoogle Scholar5 Bonapace S, Adamo E, Cicciò C, Chiampan A, Canali G, Valbusa F. Unusual echocardiographic image of a left circumflex coronary artery with anomalous origin from the right coronary sinus. Eur Heart J. 2016; 37:792. doi: 10.1093/eurheartj/ehv341CrossrefMedlineGoogle Scholar eLetters(0)eLetters should relate to an article recently published in the journal and are not a forum for providing unpublished data. 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Published on behalf of the American Heart Association, Inc., by Wiley BlackwellThis is an open access article under the terms of the Creative Commons Attribution‐NonCommercial License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes.https://doi.org/10.1161/JAHA.123.030173PMID: 37382112 Manuscript receivedMarch 27, 2023Manuscript acceptedJune 9, 2023Originally publishedJune 29, 2023 Keywordsspecificityechocardiographyanomalous coronary arterysensibilityanomalous left circumflex coronary arteryPDF download SubjectsAngiographyDiagnostic TestingEchocardiographyImaging