Cor Vasa 2025, 67(Suppl.3):47-50 | DOI: 10.33678/cor.2025.089
The RAC, bleb, and crossed aorta signs: retroaortic anomalous coronary artery visualization by transthoracic echocardiography
- a Hospital Ramón Santamarina, Sección imágenes, tomografía cardíaca. Gral. Paz 1406, Tandil, Argentina
- b Canon Medical Systems, Argentina
- c Instituto de Investigación en Ciencias de la Salud, Facultad de Ciencias de la Salud, Universidad Nacional del Centro de la Provincia de Buenos Aires; Centro Científico Tecnológico CONICET, Tandil, Argentina
Transthoracic echocardiography is a useful screening tool for identifying congenital coronary artery (CA) anomalies. It has effectively dispelled the notion that CA anatomy cannot be identified noninvasively. There are three recognized echocardiographic signs associated with anomalous left coronary artery. These signs are the retroaortic circumflex (RAC) sign, the blew sign, and the crossed aorta sign. The RAC sign is highly specific and should strongly indicate an anomalous coronary artery on echocardiogram reports. However, it is crucial to distinguish it from similar-looking structures. Therefore, coronary computed tomography angiography is recommended as the primary method for assessing known or suspected coronary anomalies.
Keywords: Blew sign, Cardiac tomography, Coronary anomalies, Circumflex anomalies, Echocardiography, Retroaortic circumflex coronary
Received: December 26, 2024; Revised: December 26, 2024; Accepted: August 13, 2025; Prepublished online: June 2, 2012; Published: September 1, 2025 Show citation
| ACS | AIP | APA | ASA | Harvard | Chicago | Chicago Notes | IEEE | ISO690 | MLA | NLM | Turabian | Vancouver |
References
- Frommelt P, Lopez L, Dimas VV, et al. Recommendations for Multimodality Assessment of Congenital Coronary Anomalies: A Guide from the American Society of Echocardiography: Developed in Collaboration with the Society for Cardiovascular Angiography and Interventions, Japanese Society of Echocardiography, and Society for Cardiovascular Magnetic Resonance. J Am Soc Echocardiogr 2020;33:259-294.
Go to original source... 
Go to PubMed... - Lopez L, Saurers DL, Barker PCA, et al. Guidelines for Performing a Comprehensive Pediatric Transthoracic Echocardiogram: Recommendations from the American Society of Echocardiography. J Am Soc Echocardiogr 2024;37:119-170. Go to original source... Go to PubMed...
- Witt CM, Elvert LA, Konik EA, et al. The RAC Sign: Retroaortic Anomalous Coronary Artery Visualization by Transthoracic Echocardiography. JACC Cardiovasc Imaging 2018;11:648-649. Go to original source... Go to PubMed...
- Mancinelli A, Golino M, Miglierina E, et al. Three Echocardiographic Signs to Identify Anomalous Origin of the Circumflex Coronary Artery from the Right Sinus of Valsalva: A Case Report. CASE (Phila) 2020;4:324-327. Go to original source... Go to PubMed...
- Wierzbowska-Drabik K, Szymczyk K, Kasprzak JD. Anomalous circumflex origin from the right coronary artery forming 'bleb sign' in transoesophageal echocardiography. Eur Heart J Cardiovasc Imaging 2014;15:932. Go to original source... Go to PubMed...
- Wierzbowska-Drabik K, Kasprzak JD, Mrozowska-Peruga E, Peruga JZ. Circumflex Origin from Right Coronary Artery--The Anomaly That Should Not Be Omitted during Echocardiography--"Crossed Aorta" and "Bleb Sign" Presentation after Stents Implantation. Echocardiography 2016;33:659-660. Go to original source... Go to PubMed...
- Massobrio L, Valbusa A, Bertero G, et al. Detection of the "Crossed Aorta Sign" during Echocardiography before Angiography. Case Rep Cardiol 2017;2017:9249821. Go to original source... Go to PubMed...
- Opolski MP, Pregowski J, Kruk M, et al. Prevalence and characteristics of coronary anomalies originating from the opposite sinus of Valsalva in 8,522 patients referred for coronary computed tomography angiography. Am J Cardiol 2013;111:1361-1367. Go to original source... Go to PubMed...
- Narula J, Chandrashekhar Y, Ahmadi A, et al. SCCT 2021 Expert Consensus Document on Coronary Computed Tomographic Angiography: A Report of the Society of Cardiovascular Computed Tomography. J Cardiovasc Comput Tomogr 2021;15:192-217. Go to original source... Go to PubMed...
- Gentile F, Castiglione V, De Caterina R. Coronary Artery Anomalies. Circulation 2021;144:983-996. Go to original source... Go to PubMed...
This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (CC BY-NC 4.0), which permits non-comercial use, distribution, and reproduction in any medium, provided the original publication is properly cited. No use, distribution or reproduction is permitted which does not comply with these terms.