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Published online before print February 11, 2003, 10.1148/radiol.2271020316
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(Radiology 2003;227:201-208.)
© RSNA, 2003

Cardiac Imaging

Coronary Artery Anomalies: Assessment with Free-breathing Three-dimensional Coronary MR Angiography1

Nicholas H. Bunce, MBBS, Christine H. Lorenz, PhD, Jennifer Keegan, PhD, John Lesser, MD, Eliana M. Reyes, MD, David N. Firmin, PhD and Dudley J. Pennell, MD

1 From the CMR Unit, Royal Brompton Hospital, Sydney St, London SW3 6NP, England (N.H.B., J.K., E.M.R., D.N.F., D.J.P.); Siemens Medical Solutions, Erlangen, Germany (C.H.L.); and Minneapolis Heart Institute, Minn (J.L.). Received March 20, 2002; revision requested June 6; revision received August 30; accepted September 30. Address correspondence to D.J.P. (e-mail: d.pennell@ic.ac.uk).


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 MATERIALS AND METHODS
RESULTS
 DISCUSSION
REFERENCES
 
PURPOSE: To evaluate a simplified protocol by using free-breathing three-dimensional (3D) coronary magnetic resonance (MR) angiography to determine the anatomy of anomalous coronary arteries, in particular the relationship of the vessels to the aortic root.

MATERIALS AND METHODS: Twenty-six patients (18 men, eight women; mean age, 50 years; age range, 18–77 years) who had a history of chest pain, palpitations, or syncope and who were suspected of having coronary artery anomalies were examined with free-breathing MR angiography. Multiple 3D volume slabs were acquired at the level of the sinuses of Valsalva by using diaphragmatic navigators for respiratory artifact suppression. The proximal anatomy of the coronary arteries was determined.

RESULTS: Six anomalous circumflex arteries originated from the right sinus of Valsalva and passed behind the aortic root. Six right coronary arteries arose from the left sinus of Valsalva and coursed between the aortic root and the right ventricular outflow tract (RVOT). Nine left coronary arteries arose from the right sinus of Valsalva; seven of nine coursed between the aortic root and the RVOT. Five patients had minor anomalies. Overall, in eight patients with anomalous arteries that coursed between the aortic root and the RVOT, conventional coronary angiography could not be used confidently to identify the proximal course.

CONCLUSION: Free-breathing 3D coronary MR angiography can be used to identify the proximal anatomy of anomalous coronary arteries.

© RSNA, 2003

Index terms: Coronary angiography, comparative studies, 54.124 • Coronary vessels, abnormalities, 54.18 • Magnetic resonance (MR), vascular studies, 54.124


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
MATERIALS AND METHODS
RESULTS
 DISCUSSION
REFERENCES
 
Congenital abnormalities of the origin and course of the coronary arteries are an uncommon but important cause of chest pain and sudden cardiac death (1,2). The incidence has been reported to be between 0.3%–1.0% of the population (3–6), although this may be an underestimate, as many asymptomatic individuals may be unrecognized. In several studies about conventional coronary angiography and in autopsy series (7,8), it has been demonstrated that approximately 60% of coronary artery anomalies involve an isolated circumflex artery, and the remaining 40% involve the right and left coronary arteries. The association of coronary artery anomalies and sudden cardiac death appears to be exclusively found in patients with an interarterial vessel, in whom the anomalous vessel passes between the aortic root and right ventricular outflow tract (RVOT) or pulmonary artery (7,8).

It is therefore vital that the precise anatomic arrangement is identified to enable the appropriate management plan (ie, surgical reconstruction or bypass graft surgery, medical therapy) to be followed. The initial diagnostic examination is typically conventional coronary angiography, during which a coronary artery will be seen to arise from an alternate sinus of Valsalva (eg, a right coronary artery from the left sinus of Valsalva) or can be seen as an early branch from a vessel (eg, a circumflex artery from the right coronary artery). However, even with multiple projections and the use of pulmonary artery catheters (9–11), the identification of the proximal course of the vessel can be difficult within the angiographic suite (12–14).

Although transesophageal echocardiography (15–18) and computed tomography (19,20) have been used to identify the proximal course of these anomalies, coronary magnetic resonance (MR) angiography has been shown to be accurate for this task in several small studies. The American Heart Association (21) supports the use of coronary MR angiography as a noninvasive tool in the examination of patients who are suspected of having anomalous coronary arteries. In the majority of published coronary MR angiographic studies, multiple breath-hold two-dimensional (2D) sections in several planes were used to image the coronary arteries, which requires considerable patient compliance and operator experience (22–25). The purpose of our study was to evaluate a simplified protocol by using free-breathing three-dimensional (3D) coronary MR angiography to determine the anatomy of anomalous coronary arteries and, in particular, the relationship of the vessels to the aortic root.


   MATERIALS AND METHODS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
RESULTS
 DISCUSSION
REFERENCES
 
Patients
Between October 1998 and March 2002, 26 patients (18 men, eight women; mean age, 50 years; age range, 18–77 years) with coronary artery anomalies were referred to our department for anatomic assessment of the origin and proximal course of the anomalies. In 25 of these patients who were examined because of chest pain, palpitations, or syncope, conventional coronary angiography was performed. The coronary artery anomaly was identified, but the relationship between the vessel and the aortic root was not clearly demonstrated. One patient was examined because of palpitations but did not undergo conventional coronary angiography. No patient had contraindications to MR imaging. The study protocol was approved by the Ethics Committee of Royal Brompton Hospital, London, England, and informed written consent was obtained from each patient.

Free-breathing 3D Coronary MR Angiography
In the first 19 patients, 3D coronary MR angiography was performed with a 1.5-T unit (Edge; Picker, Cleveland, Ohio) by using a custom-made four-channel phased-array coil centered over the precordium. In seven patients, 3D coronary MR angiography was performed with a 1.5-T unit (Sonata; Siemens, Erlangen, Germany) by using a flexible phased-array coil. With both sequences, fat suppression was used, and the sequences were cardiac gated to mid-diastole according to the patients’ cardiac motion. With the imaging unit used in 19 patients, we implemented a 3D segmented gradient-echo fast low-angle shot sequence with the following parameters: repetition time msec/echo time msec, 12.9/4.3; views, eight per data segment; acquisition window, 103.2 msec; incremental flip angle, 20°–90°; voxel dimensions, 1.0 x 1.4 x 2.5 mm. Respiratory artifact reduction was produced by using prospective respiratory gating (26) and phase reordering (27–29).

With the other MR unit used in seven patients, we performed 3D true fast imaging with steady-state precession (30) with the following parameters: 1.6/3.2; views, 12 per data segment; acquisition window, 80 msec; flip angle, 60°; voxel dimensions, 1.0 x 1.0 x 2.0 mm. Respiratory artifact reduction was produced by using prospective respiratory gating with a 5-mm acceptance window and a simple accept-reject algorithm. With both sequences, respiratory gating was performed by using a navigator pulse positioned through the dome of the right hemidiaphragm. All patients completed the MR imaging protocol with no adverse effects. The mean total scanning time was 26 minutes (range, 17–38 minutes), with 3D slab acquisition time dependent on heart rate and the stability of end expiration.

Coronary Artery Anatomy and Examination Strategy
Knowledge of the common anatomic variants of coronary artery anomalies is of great help for their identification, with particular emphasis on the appearance at MR imaging. The lone anomalous circumflex artery is the most common anatomic variant, and it occurs in approximately 0.32%–0.67% of patients who undergo conventional coronary angiography (12,31–33). The anomalous circumflex artery typically originates from a separate ostium within the right sinus of Valsalva, or as a proximal branch of the right coronary artery (Fig 1), which may be missed if a cardiac catheter passes too far down the right coronary artery. A review of findings in the published data from many angiographic and postmortem studies suggested that all anomalous circumflex coronary arteries passed behind the aortic root (8,12,23,31–35) and usually appeared more caudal than did the left coronary artery when seen with oblique sagittal coronary MR angiography.



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  		Figure 1a. (a) Anatomic representation of the normal origins of the coronary arteries as seen with transverse coronary MR angiography (viewed from the feet, looking toward the head). The anatomic landmarks can be readily identified: right ventricular outflow tract (rvot), aortic root (ao), right atrium (ra), left atrium (la), and left ventricle (lv). The right coronary artery (rca) originates from the right sinus of Valsalva and passes anteriorly in the right atrioventricular groove. The left coronary artery originates from the left sinus of Valsalva and divides into the left anterior descending artery (lad) in the interventricular groove and the circumflex artery (lcx) in the posterior atrioventricular groove. (b) Anatomic representation of the origins of the anomalous circumflex artery. The anomalous circumflex artery arises as a branch from the right coronary artery or as a separate vessel from the right sinus of Valsalva. It then passes posterior to the aortic root to enter the posterior atrioventricular groove.

 


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  		Figure 1b. (a) Anatomic representation of the normal origins of the coronary arteries as seen with transverse coronary MR angiography (viewed from the feet, looking toward the head). The anatomic landmarks can be readily identified: right ventricular outflow tract (rvot), aortic root (ao), right atrium (ra), left atrium (la), and left ventricle (lv). The right coronary artery (rca) originates from the right sinus of Valsalva and passes anteriorly in the right atrioventricular groove. The left coronary artery originates from the left sinus of Valsalva and divides into the left anterior descending artery (lad) in the interventricular groove and the circumflex artery (lcx) in the posterior atrioventricular groove. (b) Anatomic representation of the origins of the anomalous circumflex artery. The anomalous circumflex artery arises as a branch from the right coronary artery or as a separate vessel from the right sinus of Valsalva. It then passes posterior to the aortic root to enter the posterior atrioventricular groove.

 
In 0.03%–0.17% of patients who undergo angiography (31–33), the right coronary artery arises from the left sinus of Valsalva as a separate vessel or as a branch of a single coronary artery. In a large number of cases (135 of 136 patients in the largest study by Yamanaka and Hobbs [33]), the vessel coursed immediately anteriorly between the aortic root and the RVOT to enter the right atrioventricular groove (Fig 2), and this variant can be associated with sudden cardiac death in up to 30% of patients (36). The left coronary artery can arise separately from the right sinus of Valsalva or as a branch from a single coronary artery in 0.09%–0.11% of angiographic studies (31–33). The interarterial course occurs in up to 75% of patients (8,32,34), in whom the vessel passes between the aortic root and the RVOT, (Fig 3) and is associated with sudden cardiac death (7,8,37). The vessel also may course anterior to the RVOT or posterior to the aortic root, or it may follow a septal course.



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  		Figure 2a. Anatomic representation of the origins of the anomalous right coronary artery (rca). The anomalous artery arises as a branch from the left main coronary artery or as a separate vessel from the left sinus of Valsalva. (a) The anomalous artery can then pass forward in an interarterial course between the aortic root and RVOT to enter the right atrioventricular groove. (b) An alternative course is for the anomalous vessel to pass posterior to the aortic root. The anatomic landmarks are as indicated in Figure 1.

 


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  		Figure 2b. Anatomic representation of the origins of the anomalous right coronary artery (rca). The anomalous artery arises as a branch from the left main coronary artery or as a separate vessel from the left sinus of Valsalva. (a) The anomalous artery can then pass forward in an interarterial course between the aortic root and RVOT to enter the right atrioventricular groove. (b) An alternative course is for the anomalous vessel to pass posterior to the aortic root. The anatomic landmarks are as indicated in Figure 1.

 


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  		Figure 3a. Anatomic representation of the anomalous left coronary artery, which can arise as a branch from the right coronary artery or as a separate vessel from the right sinus of Valsalva. Several pathways have been described: (a) the anomalous left coronary artery courses interarterially, between the aorta and RVOT, before dividing into the left anterior descending (lad) and circumflex (lcx) arteries; the anomalous left coronary artery courses (b) posterior or (c) anterior to the aortic root before bifurcating into the left anterior descending and circumflex arteries; or (d) the left anterior descending artery arises from the right sinus of Valsalva and passes intramurally to enter the interventricular groove. The anatomic landmarks are as indicated in Figure 1.

 


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  		Figure 3b. Anatomic representation of the anomalous left coronary artery, which can arise as a branch from the right coronary artery or as a separate vessel from the right sinus of Valsalva. Several pathways have been described: (a) the anomalous left coronary artery courses interarterially, between the aorta and RVOT, before dividing into the left anterior descending (lad) and circumflex (lcx) arteries; the anomalous left coronary artery courses (b) posterior or (c) anterior to the aortic root before bifurcating into the left anterior descending and circumflex arteries; or (d) the left anterior descending artery arises from the right sinus of Valsalva and passes intramurally to enter the interventricular groove. The anatomic landmarks are as indicated in Figure 1.

 


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  		Figure 3c. Anatomic representation of the anomalous left coronary artery, which can arise as a branch from the right coronary artery or as a separate vessel from the right sinus of Valsalva. Several pathways have been described: (a) the anomalous left coronary artery courses interarterially, between the aorta and RVOT, before dividing into the left anterior descending (lad) and circumflex (lcx) arteries; the anomalous left coronary artery courses (b) posterior or (c) anterior to the aortic root before bifurcating into the left anterior descending and circumflex arteries; or (d) the left anterior descending artery arises from the right sinus of Valsalva and passes intramurally to enter the interventricular groove. The anatomic landmarks are as indicated in Figure 1.

 


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  		Figure 3d. Anatomic representation of the anomalous left coronary artery, which can arise as a branch from the right coronary artery or as a separate vessel from the right sinus of Valsalva. Several pathways have been described: (a) the anomalous left coronary artery courses interarterially, between the aorta and RVOT, before dividing into the left anterior descending (lad) and circumflex (lcx) arteries; the anomalous left coronary artery courses (b) posterior or (c) anterior to the aortic root before bifurcating into the left anterior descending and circumflex arteries; or (d) the left anterior descending artery arises from the right sinus of Valsalva and passes intramurally to enter the interventricular groove. The anatomic landmarks are as indicated in Figure 1.

 
Therefore, to include the most common locations of the origins of anomalous coronary arteries, we performed 3D coronary MR angiography by using the following simplified strategy. Both the right and left sinuses of Valsalva were identified with navigator-gated 2D-segmented fast low-angle shot gradient-echo pilot images (Fig 4). Then transverse 3D 20-mm-thick slabs were positioned at the level of the sinuses, and one or two slabs were required to adequately image the proximal arteries. For the circumflex vessels, it was necessary to repeat the 3D acquisitions beneath the right sinus of Valsalva because of the typical caudal course. To confirm the proximal course of the anomalous vessels, oblique sagittal slabs were positioned between the aortic root and the RVOT for vessels with an interarterial course, behind the aorta for retrograde vessels, and in front of the RVOT for anterograde vessels.



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  		Figure 4. Coronal pilot image. The 3D slabs (dotted lines) were positioned at the level of the left sinus of Valsalva (white arrow) and the right sinus of Valsalva (black arrow).

 
Analysis of Angiograms
Analysis of the 3D coronary MR angiograms was performed by using in-house–designed software tools (CMR Tools; Imperial College, London, England), which enabled off-line viewing of Digital Imaging and Communications in Medicine images. An experienced operator (C.H.L.) determined the anatomic position of the three coronary arteries and the proximal course in relation to the aortic root and the RVOT. Each conventional coronary angiogram was analyzed by an experienced cardiologist (J.L.) who determined the anatomic position of the three coronary arteries and the proximal course in relation to the aortic root and the RVOT. With conventional coronary angiography, the presence of significant coronary artery stenosis was noted. Both the conventional coronary angiogram and the MR angiogram were evaluated together (C.H.L., J.L., N.H.B.) to determine the final diagnosis regarding the anomalous coronary artery.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
RESULTS
DISCUSSION
REFERENCES
 
In five patients (Table), the coronary artery anomaly (ie, dual right coronary arteries arising from the right sinus of Valsalva in two patients, right coronary arteries arising anteriorly from the right sinus of Valsalva in two patients, a left coronary artery arising from the noncoronary sinus of Valsalva in one patient) was minor, with limited clinical importance apart from potentially requiring more imaging time during cardiac catheterization. All five anomalies were identified by using 3D coronary MR angiography. With conventional coronary angiography, three of four patients were identified, but in one case, a dual right coronary artery was not cannulated. One patient had not undergone conventional coronary angiography.


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  		Results of Diagnostic Conventional Coronary Angiography and 3D MR Angiography in 26 Patients

 
In the remaining 21 patients, there were six (29%) of 21 isolated anomalous circumflex arteries, all of which passed behind the aortic root (Fig 5). This was correctly determined with 3D coronary MR angiography, but with conventional coronary angiography, in one of six patients there was uncertainty about the proximal course. With conventional coronary angiography in these patients, there were no atheromatous coronary artery stenoses in the anomalous circumflex vessels, and only one patient required surgery for significant stenoses of the left anterior descending artery and first diagonal branch of a nonaberrant left coronary artery.



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  		Figure 5a. Images obtained with the true fast imaging with steady-state precession sequence (1.6/3.2; voxel dimensions, 1.0 x 1.0 x 2.0 mm; flip angle, 60°). (a) Transverse slab. Anomalous circumflex artery (arrow) courses posterior to the aortic root (*). (b) Oblique sagittal slab positioned in plane with the anomalous vessel. The anomalous circumflex artery (arrows) courses an inferior course as a branch from the right coronary artery. It passes inferior and posterior to the aortic root (*).

 


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  		Figure 5b. Images obtained with the true fast imaging with steady-state precession sequence (1.6/3.2; voxel dimensions, 1.0 x 1.0 x 2.0 mm; flip angle, 60°). (a) Transverse slab. Anomalous circumflex artery (arrow) courses posterior to the aortic root (*). (b) Oblique sagittal slab positioned in plane with the anomalous vessel. The anomalous circumflex artery (arrows) courses an inferior course as a branch from the right coronary artery. It passes inferior and posterior to the aortic root (*).

 
Six (29%) of 21 patients had right coronary arteries arising from the left sinus of Valsalva, including one patient with a single-stem vessel arising from the sinus, and all the right coronary arteries passed between the RVOT and the aortic root (Fig 6). Of these patients, one had been resuscitated from a cardiac arrest, and four had a history of angina. Three-dimensional coronary MR angiography depicted the interarterial course in six of six patients. With conventional coronary angiography, in three of six patients, the anomalous right coronary artery was not selectively cannulated, and in four of six patients, it was not possible to determine the proximal course of the artery with certainty. At conventional coronary angiography, there were no atheromatous coronary artery stenoses in the anomalous right coronary arteries, but one patient had a significant stenosis in a nonaberrant left anterior descending artery. Five of these patients underwent surgery, while the other patient with repaired tetralogy of Fallot and pulmonary regurgitation underwent medical treatment.



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  		Figure 6a. (a) Transverse 3D slabs obtained with true fast imaging with steady-state precession sequence (1.6/3/2; voxel dimensions, 1.0 x 1.0 x 2.0 mm; flip angle, 60°) show an anomalous right coronary artery (arrow) from the left sinus of Valsalva that courses intraarterially between the aortic root (*) and the RVOT (+) to enter the right atrioventricular groove. (b) Oblique sagittal image obtained with same parameters as in a demonstrates the interarterial course of the anomalous right coronary artery (arrows). (c) On a left anterior oblique straight projection conventional coronary angiogram obtained with a coronary artery catheter (Amplatz right modified), it was not possible to selectively cannulate the right coronary artery, but it filled (arrows) during contrast material injection into the aortic root; an interarterial course could not be excluded.

 


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  		Figure 6b. (a) Transverse 3D slabs obtained with true fast imaging with steady-state precession sequence (1.6/3/2; voxel dimensions, 1.0 x 1.0 x 2.0 mm; flip angle, 60°) show an anomalous right coronary artery (arrow) from the left sinus of Valsalva that courses intraarterially between the aortic root (*) and the RVOT (+) to enter the right atrioventricular groove. (b) Oblique sagittal image obtained with same parameters as in a demonstrates the interarterial course of the anomalous right coronary artery (arrows). (c) On a left anterior oblique straight projection conventional coronary angiogram obtained with a coronary artery catheter (Amplatz right modified), it was not possible to selectively cannulate the right coronary artery, but it filled (arrows) during contrast material injection into the aortic root; an interarterial course could not be excluded.

 


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  		Figure 6c. (a) Transverse 3D slabs obtained with true fast imaging with steady-state precession sequence (1.6/3/2; voxel dimensions, 1.0 x 1.0 x 2.0 mm; flip angle, 60°) show an anomalous right coronary artery (arrow) from the left sinus of Valsalva that courses intraarterially between the aortic root (*) and the RVOT (+) to enter the right atrioventricular groove. (b) Oblique sagittal image obtained with same parameters as in a demonstrates the interarterial course of the anomalous right coronary artery (arrows). (c) On a left anterior oblique straight projection conventional coronary angiogram obtained with a coronary artery catheter (Amplatz right modified), it was not possible to selectively cannulate the right coronary artery, but it filled (arrows) during contrast material injection into the aortic root; an interarterial course could not be excluded.

 
The remaining nine (43%) of 21 patients had left coronary arteries arising from the right sinus of Valsalva, and those in seven passed between the aortic root and the RVOT (Fig 7a). Of the seven patients, five underwent surgical correction. Two patients had left coronary arteries that passed anterior to the RVOT, and both received medical treatment (Fig 7b). At 3D coronary MR angiography, the interarterial course was demonstrated in seven of nine patients, and the anterior course was demonstrated in two patients. With conventional coronary angiography, there was uncertainty about the proximal course in six of nine patients, and in four of these, the course was interarterial; in one of nine patients, the left coronary artery was not identified. At conventional coronary angiography, there were no atheromatous coronary artery stenoses in the anomalous left coronary arteries.



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  		Figure 7a. (a) Transverse 3D coronary MR angiogram obtained with the fast low-angle shot sequence (12.9/4.3; voxel dimensions, 1.0 x 1.4 x 2.5 mm; incremental flip angle, 20°-90°) in an 18-year-old man with a history of exertional chest pain who collapsed while playing soccer. He was successfully resuscitated from ventricular fibrillation with five direct-current shocks. Image shows an anomalous left coronary artery (arrows) that arises from the right sinus of Valsalva and passes between the aortic root (*) and the RVOT (+) in an intraarterial course. (b) Transverse 3D coronary MR angiogram obtained with true fast imaging with steady-state precession sequence (1.6/3.2; voxel dimensions, 1.0 x 1.0 x 2.0 mm; flip angle, 60°) in a 50-year-old woman with chest pain. The left anterior descending artery (arrows) courses anteriorly to the RVOT (+).

 


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  		Figure 7b. (a) Transverse 3D coronary MR angiogram obtained with the fast low-angle shot sequence (12.9/4.3; voxel dimensions, 1.0 x 1.4 x 2.5 mm; incremental flip angle, 20°-90°) in an 18-year-old man with a history of exertional chest pain who collapsed while playing soccer. He was successfully resuscitated from ventricular fibrillation with five direct-current shocks. Image shows an anomalous left coronary artery (arrows) that arises from the right sinus of Valsalva and passes between the aortic root (*) and the RVOT (+) in an intraarterial course. (b) Transverse 3D coronary MR angiogram obtained with true fast imaging with steady-state precession sequence (1.6/3.2; voxel dimensions, 1.0 x 1.0 x 2.0 mm; flip angle, 60°) in a 50-year-old woman with chest pain. The left anterior descending artery (arrows) courses anteriorly to the RVOT (+).

 
For demonstrating the anatomic relationship between the aorta, the RVOT, and the anomalous vessels, transverse imaging appeared superior to oblique sagittal imaging, although a formal diagnostic comparison between planes was not performed.

The findings at conventional coronary angiography and coronary MR angiography are summarized in the Table. At 3D coronary MR angiography, the proximal coronary anatomy was demonstrated in all 26 patients with coronary artery anomalies. At conventional coronary angiography, the proximal course of the anomalous vessel could not be determined with certainty in 11 patients in whom there were eight anomalous vessels with an interarterial course.


   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
RESULTS
 DISCUSSION
REFERENCES
 
Study Findings
Findings of this study indicated that free-breathing 3D coronary MR angiography can depict suspected coronary artery anomalies. By using a simple protocol of transverse 3D slabs positioned at the left and right sinuses of Valsalva, with additional oblique sagittal 3D slabs positioned between the aortic root and the RVOT, all 26 patients completed the study and all anomalous vessels and their proximal courses were identified.

Researchers in previous coronary MR angiographic studies used a breath-hold 2D imaging strategy that may require considerable patient compliance and operator experience. Post et al (23) used transverse and oblique 2D breath-hold coronary MR angiography in 19 patients with anomalous coronary arteries and in 19 control subjects with normal coronary arteries. They correctly identified all the anomalous vessels, but one subject could not satisfactorily perform the repetitive breath holds, and the mean imaging time was 45 minutes.

McConnell et al (24) performed breath-hold transverse and breath-hold oblique 2D coronary MR angiography in 16 patients with anomalous coronary arteries. They correctly identified 14 of 16 anomalous coronary arteries; one patient was unable to hold a breath, and image quality in a second patient was inadequate. The mean imaging time was 50 minutes. Some patients are unable to perform repetitive breath holds, and this inability can lead to section misregistration and respiratory motion artifacts (38). The approach with 3D free breathing and diaphragmatic navigators is applicable to almost all patients and may require less operator experience once familiarity with the navigator setup is obtained. In addition, multiple 3D slabs can be rapidly acquired and then reformatted off line for accurate assessment of the proximal course of the vessel.

Compared with findings in previously published studies with 3D coronary MR angiography (39), our findings did not indicate substantial difficulty in the acquisition of the navigator-gated slabs. This may have been caused by the young age (median age, 49 years) of our study population and their lack of comorbid illnesses, such as left ventricular failure or respiratory disease. It is possible that 3D breath-hold acquisitions, as reported by Li et al (40) and Shea et al (41), could be a helpful alternative in subjects in whom poor navigator-gated images were obtained or who have a limited tolerance to the MR imaging unit.

In our study, we found that the transverse slabs provided more anatomic information and were easier to interpret than the oblique sagittal slabs. Therefore, they should be acquired first, particularly in patients with limited tolerance of the environment of the MR imaging unit. However, the oblique sagittal slabs provided excellent images of anomalous circumflex arteries.

In this study, all but one patient were referred from other hospitals because of uncertainty about the coronary artery anomaly and its proximal course after diagnostic conventional coronary angiography. These patients were referred by experienced cardiologists who were regularly performing and reporting findings at diagnostic and interventional cardiac catheterization. Several methods have been advocated to enable the identification of the course of anomalous vessels, and these methods include the simultaneous use of a pulmonary artery catheter to identify the RVOT (42), or the dot-and-eye method (a technique described in detail by Serota et al [43]).

In this latter method, the "eye" refers to the ellipse formed by an anomalous left main-stem artery and the circumflex artery, and the "dot" refers to the end-on appearances of anomalous vessels behind or in front of the aorta, but identification can be difficult to achieve with a degree of certainty. In our series, despite further review of the conventional coronary angiograms by an experienced cardiologist, it was not possible to ascertain the proximal course of 11 anomalous vessels with certainty; with coronary MR angiography, the course of all 11 vessels was demonstrated, and eight of these 11 vessels had an interarterial course.

It is important to correctly diagnose an anomalous vessel that passes between the aortic root and the RVOT, because this anatomic arrangement is associated with chest pain and sudden cardiac death, although the exact physiologic mechanism is uncertain. One explanation is that aberrant vessels with an interarterial course may have a slit-like orifice (44) that is narrowed when the aorta expands during exercise, or the vessel may have an acute angled intramural segment, or that compression occurs again between the high-pressure aorta and the RVOT during exercise (45). It is possible that in different patients different physiologic mechanisms coexist, but findings in all the studies reported suggest that it appears to be the interarterial course that causes death and ischemia.

Three-dimensional coronary MR angiography can reliably and noninvasively depict the anomalous vessels, and in the future, this modality could be combined with physiologic or pharmacologic stress testing to confirm the presence of inducible ischemia. Improvements in 3D coronary MR angiography may also allow for the assessment of coronary artery stenoses in normal and anomalous coronary arteries.

Study Limitations
In this study, we investigated the use of free-breathing 3D coronary MR angiography in the determination of the proximal anatomy of anomalous coronary arteries. A comparative study between 2D and 3D and breath-hold and non–breath-hold imaging could be performed to determine which protocol is the most time efficient and provides the optimal image quality.

Although the combination of 3D coronary MR angiography and conventional coronary angiography was used to define the "correct" anatomy, the pathologic diagnosis at surgery should be considered the reference standard. Unfortunately, this confirmatory information was obtained in only two patients with interarterial vessels who underwent surgery at Royal Brompton Hospital. Because of the lack of confirmatory information, in this study it was not possible to comment on the ostial orifice or the presence of an intramural flap as the cause of the patients’ angina or cardiac arrhythmia.

In conclusion, free-breathing 3D coronary MR angiography can help to identify the anatomy of anomalous coronary arteries, and this modality should be considered for use in patients with anomalous left and right coronary arteries in whom the proximal anatomy is uncertain after conventional coronary angiography.


   FOOTNOTES
 
Abbreviations: RVOT = right ventricular outflow tract, 3D = three-dimensional, 2D = two-dimensional

Author contributions: Guarantors of integrity of entire study, N.H.B., D.J.P., C.H.L.; study concepts, N.H.B., J.K.; study design, N.H.B., C.H.L., D.J.P.; literature research, N.H.B., C.H.L., E.M.R.; clinical studies, J.K., D.N.F., N.H.B., C.H.L.; data acquisition, N.H.B., C.H.L., J.K.; data analysis/interpretation, N.H.B., C.H.L., J.L.; statistical analysis, N.H.B., E.M.R.; manuscript preparation, N.H.B., E.M.R.; manuscript definition of intellectual content, editing, and revision/review, N.H.B., C.H.L., D.J.P.; manuscript final version approval, N.H.B., C.H.L., D.J.P., J.K.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
RESULTS
 DISCUSSION
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