The application of the latest ultrasound technology, in particular the 2^nd harmonic, has opened new roads in ultrasound coronary evaluation. By applying anatomical knowledge and the newest technical applications it is nowadays possible to propose a complete coronary evaluation of the left anterior descending artery and of a part of the posterior descending coronary artery in clinical practice 1 [see Additional File 1].

Left anterior descending (LAD) coronary anatomy was the first artery investigated with ultrasound by transesophageal and transthoracic approach. This vessel is visible by using ultrasound from proximal to distal tract and following key anatomical structures through the delivery of an ultrasound beam in an off-axis approach starting from the classical apical approach (Fig 1, 2).

Proximal Lad: the left atrial appendage and pulmonary artery represent the key reference points in detecting the proximal left anterior descending coronary tract (Fig 3, 4, 5) [see Additional File 2].

Intermediate Lad: the septal perforans branches represent the key references obtainable by angulating the probe slightly lower (3,5-5 MHz in 2^nd) and maintaining the focus on the anterior interventricular sulcus (Fig 6, 7, 8) [see Additional File 3].

Distal Lad tract: this can be highlighted by investigating the lower part of interventricular anterior sulcus near the apex under Color Doppler guidance and adopting growing delivery frequencies (5–7 Mhz in 2^nd harmonic). By subsequently applying Pulse Doppler inside the coronary vessel, we may obtain the coronary spectrum and therefore quantify it (Fig 9, 10, 11) [see Additional File 4].

For the distal left posterior coronary artery we must address the ultrasound beam in a counter-clockwise direction (Fig 1b), and, always under Color Doppler guidance, focus the ultrasound beam on the posterior descending coronary sulcus (Fig. 12, 13, 14) [see Additional File 5].

By applying the latest technology, it is nowadays possible to investigate LAD in 98% of patients and PDCA in 60–70% of patients 1, obviously delivering appropriate ultrasound frequencies for each coronary target such as summarized in Tab 1.

A good approach to the two major coronary arteries is made possible only by appropriate setting of the echo machine. To achieve this, it is important to apply the current parameters summarized in Table 1. A different application of the transducer exists for each coronary artery, ranging from lower frequencies in evaluating PDCA and proximal tract of LAD and higher frequencies for distal tract of LAD.

To obtain correct coronary flow and reserve (CFR), we need to be sure where we address the sample volume and we should be able to maintain the same position during the entire injection of the vasodilator agent. We can use Dipyridamole (0,84 mg/Kg/m' over 6 m' continuously) as well as Adenosine (140 mcg/Kg/m' for 2–3 m' with infusion time depending on operator skills) as a hyperaemic stressor. Dipyridamole is preferable because it reaches the hyperaemic peak induction more slowly and therefore it allows us to simultaneously investigate left ventricle contractility and coronary flow in different tracts of the coronary artery and to obtain a flow reserve in both coronary arteries 123.

Mistake could happen for several reasons, in particular:

For LAD:

- Mapping different coronary arteries from LAD such as Diagonal or the Intermediate branch

- Mapping different LAD tracts during the same investigation

- Misinterpreting wall noise, for example atrio-ventricular diastolic flow, as a coronary Doppler flow signal

- Misinterpreting epicardial space due to mild pericardial effusion as a coronary Doppler flow signal

-A lost coronary signal due to poor positioning of the probe during vasodilator infusion, a jumping of the investigation from one artery to another, the presence of pericardial effusion or right ventricular enlargement.

For PDCA:

- Misinterpreting wall noise, for example atrio-ventricular diastolic flow, as a coronary Doppler flow signal

- Investigating right ventricular flow, especially when this is enlarged

- Confusing the distal part of PDCA with the recurrent branch of the distal LAD tract that runs around the whole LV apex segment

- Not improving the coronary signal/noise ratio through the injection of a contrast agent

A reasonable explanation why this coronary ultrasound approach has not become as widespread as expected lies in the fact that it requires good balance in terms of anatomical and technological knowledge. As a result, a dedicated learning curve is necessary, initially resulting in a significant loss of time. To convince a wider number of operators, we may well need to develop easier technology in terms of feasibility and application. Until recently, a good coronary signal could only be obtained by adopting different multi-frequency probes. Now, with the application of a broadband transducer we can obtain an excellent color flow coronary signal simply by switching different frequencies on a single probe. It is even possible to obtain a 3-dimensional view of coronary anatomy which allows us to focus coronary direction better and, therefore to guide coronary investigation better (Fig 15) [see Additional File 6]. The high quality of Color and Pulse Doppler obtainable with this transducer could facilitate the busy sonographer and guarantee a more objective coronary flow and reserve analysis.