Detection of Coronary Artery Anomaly in Tetralogy of Fallot: Comparison of Two Angiographic Views

Background: The definite treatment of tetralogy of Fallot (TOF) as the most common cyanotic congenital heart disease is open heart surgery and the operation technique depends on the coronary artery anatomy. Objectives: We aimed to evaluate the sensitivity and specificity of various root Aortogram views to detect abnormal coronary artery configuration and course in these patients. Methods: In this retrospective study, the reports of coronary anatomy in angiography and operation notes of TOF patients since 2005 to 2018 were evaluated. The sensitivity and specificity of the two common root Aortogram views including the left anterior oblique/cranial (LAO/CRA) and left anterior oblique/caudal (LAO/CAU) were determined. Results: Four hundred and fifty one patients with the median age of 28 months (3 - 432 months) were included. All patients had LAO/CRA views and 199 patients had both LAO/CRA and LAO/CAU views. The rate of coronary abnormalities reported by surgery was 8%, and abnormal origin of the left anterior descending artery from the right coronary artery was the most common reported anomaly (4.4%). The sensitivity of the LAO/CAU view was 100%, but LAO/CRA view was about 75% in detecting abnormal coronary configuration. Both of them had excellent specificity (~ 100%). No significant sex difference was seen between different coronary anatomy abnormalities. Conclusions: The Caudal root angiogram is an essential view to evaluate coronary artery anatomy in TOF patients and it seems that there is no need for other views like lateral view, but relying on LAO/CRA view alone may lead to significant misdiagnosis of the coronary arteries, crossing the right ventricular outflow tract (RVOT).