A retroaortic course refers to a coronary artery taking its route posteriorly between the non-coronary sinus and the interatrial septum and is considered a ‘benign anomalous course’.
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Epidemiology
Associations
Clinical conditions associated with a retroaortic course of a coronary artery include 1-4:
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other congenital coronary artery anomalies
ectopic origin of the left main coronary artery
ectopic origin of the circumflex artery
other forms of congenital heart disease
Clinical presentation
Similar to a prepulmonic anomalous coronary artery course, a retroaortic course is thought to not be of increased haemodynamic risk and will be most probably found as an incidental finding on invasive coronary angiography (ICA), cardiac CT or cardiac MRI.
Radiographic features
A retroaortic coronary artery course is usually associated with an ectopic origin of either the left main coronary artery or the left circumflex artery from the right coronary sinus or the right coronary artery. It supplies the left coronary or circumflex territory and can be visualised on invasive coronary angiography (ICA) coronary CTA or coronary MR angiography as a major coronary artery coursing posterior to the aortic root, where normally no major coronary arteries are found 1,2.
Echocardiography
Several findings on echocardiography have been described, including:
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visualised from the midesophageal aortic valve long-axis view
anomalous vessel visualised in the short axis as a hypoechoic "bleb" at the mitral-aortic junction in proximity to the noncoronary cusp 10
similar structure described in the parasternal long-axis view on transthoracic echocardiography
corresponding short axis views should demonstrate this structure to be tubular to exclude the presence of artifact
Radiology report
The radiology report should include a description of the following features:
right coronary artery origin, course, segments
circumflex artery with course, branches, and segments
left main coronary artery origin and variant anatomy
left anterior descending artery with course branches and segments
coronary artery disease and stenoses with location based on the AHA coronary artery segment model
Treatment and prognosis
A retroaortic course is considered benign and not of haemodynamic importance. Management will entirely depend on symptoms and associated findings. However, it can complicate aortic valve surgery 1.