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Year : 2021  |  Volume : 31  |  Issue : 3  |  Page : 179-180

Retroaortic anomalous coronary artery visualization on transthoracic echocardiogram

1 Consultorio Cardiológico Del Sur, Juan Bautista Alberdi, Tucumán Province, Argentina
2 High-Dependency Unit, Hospital “Dr. Emilio Ferreyra”, Necochea, Buenos Aires Province, Argentina

Date of Submission17-Jan-2021
Date of Decision27-Mar-2021
Date of Acceptance06-Apr-2021
Date of Web Publication26-Oct-2021

Correspondence Address:
Pablo Blanco
High-Dependency Unit, Hospital “Dr. Emilio Ferreyra”, 4801, 59 Ave., Necochea 7630, Buenos Aires Province
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jcecho.jcecho_6_21

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Incidental findings are not uncommon in echocardiography. A transthoracic echocardiogram (TTE) of an adult woman with arterial hypertension showed a tubular structure with hyperechoic walls in the atrial side of the atrioventricular groove in apical views. Coronary computed tomography angiography correlated this finding with a retroaortic course of the anomalous circumflex artery (retroaortic anomalous coronary artery [RAC], benign coronary artery variant). Recently described as the RAC sign on TTE, practitioners should be aware of this finding to avoid mistaken it as artifacts, catheters/leads, or calcified mitral annulus.

Keywords: Coronary vessel anomalies, computed tomography angiography, incidental findings, transthoracic echocardiography

How to cite this article:
López VC, Blanco P. Retroaortic anomalous coronary artery visualization on transthoracic echocardiogram. J Cardiovasc Echography 2021;31:179-80

How to cite this URL:
López VC, Blanco P. Retroaortic anomalous coronary artery visualization on transthoracic echocardiogram. J Cardiovasc Echography [serial online] 2021 [cited 2021 Dec 8];31:179-80. Available from: https://www.jcecho.org/text.asp?2021/31/3/179/329314

  Introduction Top

Incidental findings are not uncommon in echocardiography. While there is a wide range of well-known abnormalities with variable significance, some may be unfamiliar to the practicing physician and therefore should not be neglected or mistaken as other diagnoses.

  Case Report Top

A 62-year-old woman with a history of long-lasting arterial hypertension was evaluated in the cardiac ambulatory clinic. The patient was in good general condition and did not manifest dyspnea or chest pain; she did not receive medications as well. Blood pressure in both arms was 150/90 mmHg, while the remaining of the vital signs were entirely normal. Physical examination was unremarkable, while the 12-lead electrocardiogram showed signs of left ventricular hypertrophy.

Transthoracic echocardiogram (TTE) showed mild left ventricular hypertrophy. In apical views, a tubular structure with hyperechoic walls was observed along the atrial side of the atrioventricular groove [Figure 1]a and [Figure 1]b and Videos 1 and 2]. For defining the origin of this finding, a coronary computed tomography (CT) angiogram was performed demonstrating the absence of the left main coronary artery, the left anterior descending artery originating directly from the left sinus of Valsalva, and the circumflex artery originating from the right sinus of Valsalva, independently of the right coronary artery origin [Figure 1]c and [Figure 1]d. The circumflex artery encircled the noncoronary sinus of Valsalva and then directed posterior to the aorta, ran within the left atrioventricular groove, and finally, ended at the lateral wall of the left ventricle [Figure 1]c and [Figure 1]d. No stenosis was found in the coronary arteries, and the coronary calcium score was 0.
Figure 1: Upper panel. Retroaortic anomalous coronary artery visualization (“Retroaortic anomalous coronary artery sign”, arrows) on transthoracic echocardiogram. (a) Apical 5-chamber view; (b) Apical 3-chamber view. Lower panel (c and d). Coronary computed tomography angiogram showed the circumflex artery (CX) originating from the right sinus of Valsalva independently of the right coronary artery (RCA); it partially encircled the aortic valve along the noncoronary cusp and then traveled retroaortic

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The patient started on antihypertensive drugs with an optimal control of arterial hypertension on follow-up visits.

  Discussion Top

Coronary anomalies occur in 1.3% of population.[1] Retroaortic anomalous coronary artery (RAC) is a variant involving the circumflex artery that originates from either the right coronary artery or the right coronary cusp. It is considered a benign anomaly given that is no related to myocardial ischemia or sudden cardiac death.[2] Nevertheless, given that the involved vessel partially encircles the aortic valve, concerns exist about its potential injury during the surgery of the valve.[2] Regarding the diagnosis, this anomaly may be suspected when the RAC sign is observed on TTE; however, this is an incidental finding that is often neglected by operators. The RAC sign was recently described in the literature, with a reported sensitivity of 63.3% and specificity of 93.4% and it should be distinguished from catheters/leads, artifacts, or calcified mitral annulus.[3] Coronary CT angiography in the first place or eventually magnetic resonance imaging aids in confirming the diagnosis;[2] however, given the benign nature of the RAC, studying all the patients is not mandatory when the RAC sign is observed in isolation on TTE, and therefore, it may be considered when there is suspicion of coronary stenosis, when planning aortic valve surgery, or eventually for estimating the patient's cardiovascular risk.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Yamanaka O, Hobbs RE. Coronary artery anomalies in 126,595 patients undergoing coronary arteriography. Cathet Cardiovasc Diagn 1990;21:28-40.  Back to cited text no. 1
Shriki JE, Shinbane JS, Rashid MA, Hindoyan A, Withey JG, DeFrance A, et al. Identifying, characterizing, and classifying congenital anomalies of the coronary arteries. Radiographics 2012;32:453-68.  Back to cited text no. 2
Witt CM, Elvert LA, Konik EA, Ammash NM, Foley DA, Foley TA. The RAC sign: Retroaortic anomalous coronary artery visualization by transthoracic echocardiography. JACC Cardiovasc Imaging 2018;11:648-9.  Back to cited text no. 3


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