Coronary arterial lesion assessment in children can be difficult, depending on the coronary dominance pattern. Although it is easier to determine coronary dominance with echocardiography in children than in adults, it is still difficult. This study aimed to examine the coronary dominance pattern according to the objective coronary artery (CA) indices.
The CA diameter, aortic valve annulus, and abdominal aorta of 69 children without any cardiovascular disease were measured with cross-sectional echocardiography at Chungnam National University Hospital. To evaluate the coronary dominance pattern, echocardiography was primarily used; additionally, coronary computed tomographic angiography or coronary angiography (CAG). Coronary dominance was determined according to the status of the CA that gives rise to the posterior descending artery.
The mean age was 4.02±2.78 years, and the mean body surface area (BSA) was 0.70±0.22 m2 . Right dominance was present in 78% and left in 22% of the subjects. In those with left dominance, the CA to aortic valve annulus diameter ratio was 0.125±0.021 in the right coronary artery (RCA) and 0.255±0.032 in the left coronary artery (LCA). In those with right dominance, the corresponding ratio was 0.168±0.028 in the RCA and 0.216±0.030 in the LCA (
The CA indices showed significant difference according to the coronary dominance pattern in early childhood. It is possible to indirectly determine the coronary dominance pattern with the CA indices in children using echocardiography. The accuracy of coronary artery lesion diagnosis can be improved by taking coronary dominance into account.
Variants of coronary artery (CA) anatomy are encountered in several types of congenital heart disease. Kawasaki disease (KD) is the most common cause of acquired heart disease in children living in developed countries. The diagnosis relies on clinical observation, and, in most cases, CA dilation or aneurysms are assessed using echocardiography [
The subjects of the study were 69 children (32 boys and 37 girls) who were referred to the Department of Pediatrics at Chungnam National University Hospital between June 2017 and June 2018. Children included in the study were subjected to full clinical and echocardiographic examinations before enrollment. Criteria for children included in the study were that they were between 3 months and 13 years of age, that they had structurally normal hearts with normal clinical and echocardiography examinations, and that echocardiography was to be performed for one of the following reasons: evaluation of asymptomatic cardiac murmurs, musculoskeletal chest pain, or a suspected abnormal chest X-ray. In 5 of 69 subjects, coronary angiography (CAG) or CCTG was performed for the evaluation of uncertain CALs or anomalies.
The subjects were examined using an ultrasound system (Vivid 7 imaging system, GE, Chicago, IL, USA) connected to standard transthoracic transducers, in the supine or lateral decubitus position. For each subject, the highest frequency transducer with adequate penetrance was used. All standard and modified apical, parasternal, and subcostal views were used to follow the course of the left main coronary artery, left anterior descending coronary artery, left circumflex coronary artery (LCX), and RCA, from the start of each artery and distally as far as possible using a previously published technique [
Statistical analysis was performed using IBM SPSS Statistics ver. 23.0 (IBM Co., Armonk, NY, USA). All data are presented as means and standard deviations. The CA indices were visualized separately for each pattern of coronary dominance using Sigma plot version 12.0 (Merck KGaA, Darmstadt, Germany). An independent paired
The mean age of the subjects was 4.02±2.78 years (3 months–13 years), and the sex ratio was 0.86:1 (32 boys and 37 girls). The mean weight was 17.79±7.75 kg (7.8–50 kg), and the mean BSA was 0.70± 0.22 m2 (0.34–1.47 m2). Age, body weight, and BSA were not significantly different between the patterns of coronary dominance (
A significant difference was found between the study by Tan et al. [
In left coronary dominance, the diameter ratio of the CA to the BSA was 0.509±0.134 in the LCA and 0.246±0.053 in the RCA, whereas the ratio in right coronary dominance was 0.409±0.099 in the LCA and 0.316±0.069 in the RCA, showing significant differences between the LCA and RCA ratios to the BSA in both coronary dominance patterns (
In the present study, right dominance was present in 78% and left in 22% of the subjects. Significant differences were found in the diametric ratios of CA to aortic valve annulus, BSA, and abdominal aorta according to coronary dominance pattern in early childhood.
Although CAG and CCTA are sometimes performed to obtain clear information about the CA (such as CA anatomy and extent of stenosis, obstruction, or aneurysm), their use in children are limited. Therefore, echocardiography is the primary imaging modality for cardiac assessment because it is noninvasive and has high sensitivity and specificity for the detection of abnormalities of the CA segments [
The artery that supplies the PDA and a posterolateral branch determines the pattern of coronary dominance. Therefore, 3 situations are possible with normal variation: right dominance (approximately 70%–80% of the cases; supply from the RCA), left dominance (5%–10%; supply from the left circumflex coronary artery), and a balanced CA system (10%–20%) [
The diameter ratio of the LCA to the RCA in patients with left coronary dominance was approximately 1.62, and this finding was similar to that reported by Dodge et al. [
CA indices were significantly different according to the pattern of coronary dominance in the present study. Therefore, to assess CAL abnormality in children, the pattern of coronary dominance should first be determined, and CA indices can be useful in determining the coronary dominance.
It is difficult to determine coronary dominance with echocardiography as accurately as with CAG or CCTA. Owing to the small sample size, data were not analyzed according to sex or age. In conclusion, coronary artery indices showed significant differences according to coronary dominance patterns in early childhood. CA indices can be useful in determining the coronary dominance.
No potential conflict of interest relevant to this article was reported.
Demographic characteristics of the study group
Characteristic | Total (n=69) | Left dominant pattern (n=15) | Right dominant pattern (n=54) |
---|---|---|---|
Age (yr) | 4.02±2.78 | 4.01±3.18 | 4.02±2.69 |
Sex, male:female | 32:37 | 11:4 | 21:33 |
BW (kg) | 17.79±7.75 | 15.74±4.86 | 18.37±8.34 |
BSA (m2) | 0.70±0.22 | 0.65±0.17 | 0.71±0.23 |
Values are presented as mean±standard deviation or number.
BW, body weight; BSA, body surface area.
Coronary artery indices according to the dominant coronary arterial pattern: comparison with the studies of Choi et al. [
Variable | Left dominant (n=15) | Right dominant (n=54) | Tan et al. (n=390) | Choi et al. (n=83) |
---|---|---|---|---|
LCA/AoA | 0.255±0.032 | 0.216±0.030 | - | |
RCA/AoA | 0.125±0.028 | 0.202±0.027 | - | |
RCA/LCA | 0.495±0.082 | 0.785±0.118 | - |
Values are presented as mean±standard deviation.
LCA, left coronary artery; RCA, right coronary artery; AoA, aortic annulus; LCA/AoA, left and right dominant vs. Tan et al.; RCA/AoA, left and right dominant vs. Tan et al.; RCA/LCA, left dominant vs. Choi et al.
*Boldface indicates a statistically significant difference with
Difference in the coronary arterial indices according to dominant coronary artery pattern
Pattern | Left dominant pattern | Right dominant pattern | |
---|---|---|---|
LCA/BSA | 0.509±0.134 | 0.409±0.099 | |
RCA/BSA | 0.246±0.053 | 0.316±0.069 | |
LCA/AoA | 0.255±0.032 | 0.216±0.030 | |
RCA/AoA | 0.125±0.028 | 0.202±0.027 | |
LCA/dAo | 0.358±0.048 | 0.299±0.041 | |
RCA/dAo | 0.176±0.033 | 0.233±0.034 |
Values are presented as mean±standard deviation.
LCA, left coronary artery; RCA, right coronary artery; AoA, aortic annulus; BSA, body surface area; dAo, descending aorta.
Boldface indicates a statistically significant difference with