Echocardiographic Assessment of the Coronary Arteries: Seek and You Shall Find

The latest guideline document for performing a comprehensive echocardiographic examination suggests that analysis of the coronary arteries may be neglected. We provide examples of how transesophageal echocardiography can be used to visualize coronary circulation. Manipulation of the transesophageal echocardiography probe from the midesophageal aortic valve short-axis view will reveal the left main coronary artery and its bifurcation into the left circumflex and the left anterior descending coronary arteries (Fig 1, A). The right coronary artery take-off can also be seen by careful probe manipulation of the midesophageal aortic valve long-axis view. An example in this imaging plane is illustrated in Figure 1, B, in which a MitraClip is embolized to the right coronary ostium. Coronary artery stents that extend into the aortic root also may be observed rarely (Fig 1, C). Stent protrusion is thought to occur due to longitudinal stent deformation, anomalous origin of the coronary ostium, or after chest contusion events. Stent protrusion can lead to acute perforation of the aortic valve, severe aortic insufficiency, and pulmonary edema. Benign coronary anomalies may be interpreted as pathologic. For example, a small echodensity adjacent to the aortic valve in the midesophageal aortic valve long-axis view may represent an anomalous left circumflex coronary artery originating from the right coronary artery (Fig 1, D). Anomalous origin of the left main coronary artery from the right coronary artery also may be observed in the midesophageal aortic valve short-axis or long-axis view (Fig 1, E).