Abstract:
Objective: To summarize the diagnostic experience of echocardiography in pediatric patients with anomalous origin of the coronary arteries (AOCA), with a focus on identifying characteristic imaging features, analyzing the causes of missed diagnosis, and exploring strategies to improve diagnostic accuracy.
Methods: Clinical data of children diagnosed with AOCA at Beijing Children's Hospital were retrospectively reviewed. The study primarily covered two subtypes: anomalous left coronary artery from the pulmonary artery (ALCAPA) and anomalous aortic origin of a coronary artery (AAOCA). Echocardiographic manifestations, initial diagnostic results, imaging findings from supplemental modalities, and the diagnostic process were systematically analyzed. Missed diagnosis rates and underlying reasons were also evaluated.
Results: Echocardiography achieved high diagnostic accuracy for ALCAPA, with characteristic findings including left ventricular dysfunction, marked dilation of the right coronary artery, abnormal retrograde flow signals within the pulmonary artery, and collateral circulation between the coronary arteries. In contrast, the detection rate for AAOCA was substantially lower. Missed diagnoses in AAOCA were primarily attributed to nonspecific clinical presentations, insufficient attention to the aortic root anatomy, and failure to identify the abnormal origin and interarterial course of the anomalous coronary artery. In AAOCA cases where diagnosis was established, echocardiography often revealed an oval-shaped orifice or slit-like ostium at the anomalous origin, as well as an oblique course between the aorta and pulmonary trunk. Exercise-induced chest pain or syncope in these patients served as important clinical clues suggesting high-risk anatomical variants. Additional imaging modalities, including cardiac computed tomography angiography (CTA) or magnetic resonance imaging, were frequently required to confirm the diagnosis and delineate the precise course of the anomalous vessel, particularly in AAOCA.
Conclusion: Echocardiography remains the first-line screening tool for AOCA, demonstrating excellent performance in ALCAPA detection. However, its diagnostic value for AAOCA is limited, and a high index of suspicion combined with systematic evaluation of the coronary ostia and proximal course is essential to reduce missed diagnoses. When echocardiographic findings are equivocal or high-risk features are suspected, prompt integration of cross-sectional imaging techniques is strongly recommended to ensure timely and accurate diagnosis.
