Sonography of Coronary Arteries

  • Harald Becher
  • Andreas Helfen


This chapter provides clinical guidance for the sonography of coronary arteries in adults without and with signal enhancement by contrast agents. The direct in indirect criteria on how to diagnose stenoses of the epicardial coronary arteries are included and illustrated on multiple slides and movies. The measurement of the coronary flow velocity reserve and the interpretation of the results is described in detail.

Supplementary material

Video 4.1

Adenosine stress echocardiography, 4-chamber view, normal findings. Still frames recorded in systole (top) and diastole (bottom). Subendocardial reduction of myocardial opacification in late systole (last frame in top row) as well in early and mid-diastole (bottom, first two frames at the left). No left ventricular hypertrophy, heart rate 84/min (WMV 818 kb)

Video 4.2

Adenosine stress echocardiography, 2-chamber view of a patient with left ventricular hypertrophy and heart rate of 112/min. Subendocardial reduction of myocardial opacification at mid systole and lasting until mid-diastole (WMV 608 kb)

Video 4.3

Parasternal short axis section at the level of the aortic valve. On colour Doppler display of blood flow in the left main coronary artery with aliasing, which indicates stenosis in the main stem of the left coronary artery (WMV 341 kb)

Video 4.4a

Modified 2-chamber view (left) showing a stripe of colour signals of a small pericardial effusion and colour signals of the LAD in the interventricular sulcus (WMV 411 kb)

Video 4.4b

After rotation of the probe for a long axis view (right) the colour Doppler signals of the pericardial effusion are not following the interventricular sulcus but remain in the epicardial space (WMV 547 kb)

Video 4.5

Colour Doppler recording of the LAD in the interventricular sulcus, parasternal short axis view (WMV 164 kb)

Video 4.6

Colour Doppler recording of the LAD in a modified parasternal longitudinal axis according Fig. 4.16. The movement of the myocardium adjacent to the LAD may cause colour Doppler artefacts. Therefore, the PFR was increased and the baseline was shifted towards positive velocities (WMV 310 kb)

Video 4.7

Parasternal long axis modified by a tilting of the transducer cranially. The cusps of the aortic valve are not visible any more in this scan plane, instead the left coronary sinus is displayed with the proximal left coronary artery (WMV 401 kb)

Video 4.8

Modified parasternal long axis, red coded flow towards the transducer in the LAD. The blood flow in the circumflex artery is directed away from the transducer and displayed in blue colours (WMV 223 kb)

Video 4.9

Parasternal short axis view at the level of the aortic root (left) and with the probe slightly tilted caudally towards the apex. The first septal branch is directed towards the interventricular septum (left), whereas the LAD is directed to the interventricular sulcus and RVOT on the right of the recording (WMV 270 kb)

Video 4.10

Apical 4-chamber view displaying the distal LAD according to Fig. 4.22 (WMV 6288 kb)

Video 4.11

Modified apical 4-chamber view (see Fig.4.24) displaying the aortic root and the left sinus of the aortic root in the centre of the image. The colour Doppler shows the course of the left main stem and the proximal LAD which is visible for more than 7 cm. The baseline of the colour Doppler was not shifted towards positive velocities. Note distracting colour signals in the adjacent myocardium without the shift of the baseline of the colour Doppler (see Video 4.12) (WMV 591 kb)

Video 4.12

Left main stem and proximal LAD in a modified parasternal short axis. By tilting the transducer caudally, the pulmonary artery is no longer in the imaging plane. Only the RVOT and parts of the pulmonary valve are displayed (WMV 188 kb)

Video 4.13

Left main stem and proximal circumflex artery in a modified 4-chamber view, tilting the transducer cranially (WMV 288 kb)

Video 4.14

Display of parts of the circumflex artery and marginal branches at the anterolateral wall according to the diagram to Fig. 4.29 (WMV 159 kb)

Video 4.15

Posterolateral branches of the circumflex artery in a modified 4-chamber view (see Fig. 4.31). The LV shape becomes ellipsoid and the LA is out of plane (WMV 210 kb)

Video 4.16

Left main stem and proximal right coronary artery in a parasternal short axis view. In this plane it is not possible to record adequate Doppler signals of the blood blow in the proximal right coronary artery (WMV 291 kb)

Video 4.17

Modified parasternal long axis view intersecting the right sinus of the aortic root. The arrow points to colour Doppler signals of the right coronary artery (WMV 162 kb)

Video 4.18

Apical 2-chamber view. The PDA is displayed along the mid inferior segment (WMV 252 kb)

Video 4.19

4-Chamber view tilted inferiorly showing the PDA according to Fig. 4.38 (WMV 210 kb)

Video 4.20

4-Chamber view, probe tilted caudally towards the diaphragm. Crux cordis with bifurcation into PDA and PLA according to Fig. 4.40 (WMV 254 kb)

Video 4.21

Subcostal view showing the right coronary artery (RCA) in the neighbourhood of the tricuspid ring. The flow in the RCA is directed away from the transducer. The flow is coded in red colours because the colour scale is inverted (WMV 281 kb)

Video 4.22

4-Chamber view tilted inferiorly according to Video 4.18. Blue coded retrograde flow in the PDA due to occlusion of the proximal RCA (WMV 288 kb)

Video 4.23

Modified parasternal long axis view showing septal collaterals from the LAD to the PDA in a patient with proximal occlusion of the RCA. In order to optimize the colour Doppler signals of the collaterals the baseline of the colour Doppler display was shifted downward and the gain was increased. Note the increased noise—patchy colour Doppler signals—caused by the increased gain (WMV 547 kb)

Video 4.24

Modified parasternal long axis view. The blood flow in the LIMA bypass graft to the LAD is directed away from the transducer and coded in blue colours. The PW Doppler spectrum confirms the flow direction and the deceleration is shortened. The flow in the LAD has the same colours which indicate retrograde flow. Note the stenosis marked by aliasing in the LAD proximal to anastomosis of the bypass (WMV 958 kb)

Video 4.25

Modified parasternal long axis view showing a double structure, which originates from right sinus of the aortic root. This is typical of an anomalous origin of the left main coronary artery (LMCA) (WMV 371 kb)

Video 4.26

Same patient as in Video 4.25. In the apical 4-chamber view showing the double structure of the left coronary artery superimposed to the proximal interatrial septum (WMV 374 kb)

Video 4.27

Parasternal long axis according Fig. 4.16 (left). Aliasing phenomenon of the LAD flow indicating flow acceleration in the area of proximal LAD stenosis (WMV 188 kb)

Video 4.28

Severe stenosis of the left main stem resulting in aliasing of the colour Doppler signals. The baseline of the colour Doppler scale was shifted upward, corresponding to a Nyquist limit 38 cm/s. Because the recordings were performed after injection of an ultrasound contrast agent, the mechanical index (MI) was reduced to 0.1 for the colour Doppler and the PW-Doppler recordings (WMV 201 kb)

Video 4.29

Coronary angiography of the patient from Video. 4.28. Severe distal left main stem stenosis (WMV 3091 kb)

Video 4.30

Contrast enhanced colour Doppler imaging of the LAD flow in the parasternal short axis view according to Fig. 4.13 at rest (left) and during infusion of adenosine (right). Note the aliasing indicating higher flow velocities during infusion of adenosine (WMV 584 kb)

Video 4.31

Colour Doppler imaging of the LAD without contrast enhancement (WMV 1366 kb)

Video 4.32

Coronary angiography: mild stenosis and calcification in segment 6 of the LAD, FFR = 0.83 (WMV 3341 kb)


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Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Harald Becher
    • 1
  • Andreas Helfen
    • 2
  1. 1.University of Alberta HospitalEdmontonCanada
  2. 2.St. Marien Hospital, Katholisches Klinikum Lünen GmbHLünenGermany

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