Clinical Images

Preprocedural Utility of the Echocardiographic Retroaortic Anomalous Coronary Sign

Brody D. Slostad, MD1;  Chance M. Witt, MD2;  Abdallah El Sabbagh, MD2;  Thomas A. Foley, MD2

Brody D. Slostad, MD1;  Chance M. Witt, MD2;  Abdallah El Sabbagh, MD2;  Thomas A. Foley, MD2

J INVASIVE CARDIOL 2018;30(8):E73-E74.

Key words: angiography, cardiac imaging, congenital heart disease, echocardiography 

A 59-year-old man with a history of ST-elevation myocardial infarction and heart failure presented for further management of worsening paroxysmal nocturnal dyspnea and orthopnea. Echocardiogram revealed an ejection fraction of 17%, severe mitral regurgitation, and severe inferior and lateral wall-motion abnormalities. Further review of the echocardiographic apical four-chamber views revealed the recently described retroaortic anomalous coronary (RAC) sign (Figures 1A-1C).

Review of the previous cardiac catheterization from an outside hospital confirmed an anomalous left circumflex (LCX) originating from the proximal right coronary artery (RCA) that was treated with a drug-eluting stent (DES) (Figures 2A and 2B). Subsequent catheterization showed in-stent restenosis of the DES (Figures 2C and 2D).

The positive RAC sign on echocardiography, which demonstrated an anomalous retroaortic LCX from the RCA, forewarned that percutaneous coronary intervention (PCI) could be potentially high risk and technically challenging. In this setting, a cardiac magnetic resonance imaging myocardial viability study was performed for further consideration of PCI.  This revealed a 50% thickness infarct in the LCX territory (Figure 1D). Given the extent of the infarcted myocardium and technically challenging anomalous LCX, medical therapy alone was pursued.

The echocardiographic RAC sign demonstrates excellent specificity and correlation with retroaortic anomalous coronary arteries without exposure to radiation, contrast dye, or an invasive procedure. This case highlights the echocardiographic findings associated with the RAC sign and its utility as a non-invasive modality to recognize technically complex and high-risk retroaortic coronary anomalies prior to PCI or aortic intervention (Figure 1). The ability to identify an anomalous coronary artery with a non-invasive modality such as echocardiography may allow for better preprocedural preparation and outcomes.

From the 1Department of Internal Medicine and 2Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.

Manuscript accepted March 19, 2018. 

Address for correspondence: Brody D. Slostad, MD, Department of Internal Medicine, 200 1st St SW, Rochester, MN 55905. Email: