Imaging the coronary artery: is it really normal? How to avoid common echocardiographic pitfalls.

Coronary artery anomalies in the absence of structural heart defects are rare with an estimated prevalence of 0.6% to 1.2% in the general population.1 Although the anomalous left coronary artery (LCA) from the right cusp is quite rare (0.03%–0.05% estimated prevalence2), it is frequently associated with sudden cardiac death, especially when intramural.3 A similar presentation has been described in 30% of patients with a right coronary artery from the left cusp.4 Given the unknown prevalence of this disease, the natural history of these lesions has not been truly defined. Transthoracic echocardiography remains the primary screening tool in young patients with exercise-induced cardiac symptoms.3 The accuracy of this modality in identifying the abnormal origin and course of coronaries has not been established, in part due to the unknown prevalence of the disease. The technical challenge of transthoracic echocardiography lies in obtaining reliable images of relatively small structures with translational movement during the cardiac cycle.3 Few prospective studies have sought to evaluate and overcome the limitations of transthoracic echocardiography. Transesophageal echocardiography,