1
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Gräni C, Stark AW, Lo Rito M, Frigiola A, Siepe M, Tchana B, Cipriani A, Zorzi A, Pergola V, Crea D, Sarris G, Protopapas E, Sirico D, Di Salvo G, Pegoraro C, Sarto P, Francois K, Frigiola A, Cristofaletti A, Accord RE, Gonzalez Rocafort A, Debeco G, Padalino M. First report from the European registry for anomalous aortic origin of coronary artery (EURO-AAOCA). INTERDISCIPLINARY CARDIOVASCULAR AND THORACIC SURGERY 2024; 38:ivae074. [PMID: 38648747 PMCID: PMC11101283 DOI: 10.1093/icvts/ivae074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 03/21/2024] [Accepted: 04/18/2024] [Indexed: 04/25/2024]
Abstract
OBJECTIVES Anomalous aortic origin of a coronary artery (AAOCA) is a group of rare congenital heart defects with various clinical presentations. The lifetime-risk of an individual living with AAOCA is unknown, and data from multicentre registries are urgently needed to adapt current recommendations and guide optimal patient management. The European AAOCA Registry (EURO-AAOCA) aims to assess differences with regard to AAOCA management between centres. METHODS EURO-AAOCA is a prospective, multicentre registry including 13 European centres. Herein, we evaluated differences in clinical presentations and management, treatment decisions and surgical outcomes across centres from January 2019 to June 2023. RESULTS A total of 262 AAOCA patients were included, with a median age of 33 years (12-53) with a bimodal distribution. One hundred thirty-nine (53.1%) were symptomatic, whereas chest pain (n = 74, 53.2%) was the most common complaint, followed by syncope (n = 21, 15.1%). Seven (5%) patients presented with a myocardial infarction, 2 (1.4%) with aborted sudden cardiac death. Right-AAOCA was most frequent (150, 57.5%), followed by left-AAOCA in 51 (19.5%), and circumflex AAOCA in 20 (7.7%). There were significant differences regarding diagnostics between age groups and across centres. Seventy-four (28.2%) patients underwent surgery with no operative deaths; minor postoperative complications occurred in 10 (3.8%) cases. CONCLUSIONS Currently, no uniform agreement exists among European centres with regard to diagnostic protocols and clinical management for AAOCA variants. Although surgery is a safe procedure in AAOCA, future longitudinal outcome data will hopefully shed light on how to best decide towards optimal selection of patients undergoing revascularization versus conservative treatment.
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Affiliation(s)
- Christoph Gräni
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Anselm W Stark
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Mauro Lo Rito
- Department of Congenital Cardiac Surgery, IRCCS Policlinico San Donato, Milan, Italy
| | - Alessandro Frigiola
- Department of Congenital Cardiac Surgery, IRCCS Policlinico San Donato, Milan, Italy
| | - Matthias Siepe
- Department of Cardiac Surgery, Cardiovascular Center, Inselspital Universitatsspital Bern, Bern, Switzerland
| | - Bertrand Tchana
- Struttura Semplice Dipartimentale di Cardiologia Pediatrica, Dipartimento Materno-Infantile, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Alberto Cipriani
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Cardiology Clinic, University of Padova, Padova, Italy
| | - Alessandro Zorzi
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Cardiology Clinic, University of Padova, Padova, Italy
| | - Valeria Pergola
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Cardiology Clinic, University of Padova, Padova, Italy
| | - Domenico Crea
- Pediatric and Congenital Cardiac Surgery Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - George Sarris
- 2nd Department of Pediatric and Congenital Cardiac Surgery, Mitera Children’s Hospital, Athens Heart Surgery Institute, Athens, Greece
| | - Elephterios Protopapas
- 2nd Department of Pediatric and Congenital Cardiac Surgery, Mitera Children’s Hospital, Athens Heart Surgery Institute, Athens, Greece
| | - Domenico Sirico
- Pediatric Cardiology, Department of Woman and Child’s Health, University of Padova, Padova, Italy
| | - Giovanni Di Salvo
- Pediatric Cardiology, Department of Woman and Child’s Health, University of Padova, Padova, Italy
| | - Cinzia Pegoraro
- UOC Medicina dello Sport, Ospedale Ca’ Foncello, Treviso, Italy
| | - Patrizio Sarto
- UOC Medicina dello Sport, Ospedale Ca’ Foncello, Treviso, Italy
| | - Katrien Francois
- Department of Cardiac Surgery, University Hospital Ghent, Ghent, Belgium
| | - Alessandra Frigiola
- Guy and St Thomas Hospital, NHS foundation Trust and King’s College, London, UK
| | | | - Ryan E Accord
- Pediatric and Congenital Cardiothoracic Surgery, Thoraxcenter/Center for Pediatric and Congenital Heart Disease, Groningen, Netherlands
| | | | | | - Massimo Padalino
- Pediatric and Congenital Cardiac Surgery Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padova, Italy
- Department of Precision and Regenerative Medicine and Ionian Area, University of Bari Aldo Moro, Bari, Italy
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Serafini L, Piazzani M, Madureri A, Giacomarra G, Elia S, Chizzola G, Metra M, Adamo M. Anomalous origin of the coronary arteries: a brief summary for clinical practice. J Cardiovasc Med (Hagerstown) 2024; 25:364-369. [PMID: 38555582 DOI: 10.2459/jcm.0000000000001607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Affiliation(s)
- Lisa Serafini
- Institute of Cardiology, ASST Spedali Civili, Department of Medical and Surgical specialties, Radiological sciences and Public Health, University of Brescia
| | | | | | | | - Stefano Elia
- Radiology Unit, ASST Valcamonica, Esine, Brescia, Italy
| | - Giuliano Chizzola
- Institute of Cardiology, ASST Spedali Civili, Department of Medical and Surgical specialties, Radiological sciences and Public Health, University of Brescia
| | - Marco Metra
- Institute of Cardiology, ASST Spedali Civili, Department of Medical and Surgical specialties, Radiological sciences and Public Health, University of Brescia
| | - Marianna Adamo
- Institute of Cardiology, ASST Spedali Civili, Department of Medical and Surgical specialties, Radiological sciences and Public Health, University of Brescia
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Gaudino M, Di Franco A, Arbustini E, Bacha E, Bates ER, Cameron DE, Cao D, David TE, De Paulis R, El-Hamamsy I, Farooqi KM, Girardi LN, Gräni C, Kochav JD, Molossi S, Puskas JD, Rao SV, Sandner S, Tatoulis J, Truong QA, Weinsaft JW, Zimpfer D, Mery CM. Management of Adults With Anomalous Aortic Origin of the Coronary Arteries: State-of-the-Art Review. Ann Thorac Surg 2023; 116:1124-1141. [PMID: 37855783 DOI: 10.1016/j.athoracsur.2023.09.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/16/2023] [Indexed: 10/20/2023]
Abstract
As a result of increasing adoption of imaging screening, the number of adult patients with a diagnosis of anomalous aortic origin of the coronary arteries (AAOCA) has grown in recent years. Existing guidelines provide a framework for management and treatment, but patients with AAOCA present with a wide range of anomalies and symptoms that make general recommendations of limited applicability. In particular, a large spectrum of interventions can be used for treatment, and there is no consensus on the optimal approach to be used. In this paper, a multidisciplinary group of clinical and interventional cardiologists and cardiac surgeons performed a systematic review and critical evaluation of the available evidence on the interventional treatment of AAOCA in adult patients. Using a structured Delphi process, the group agreed on expert recommendations that are intended to complement existing clinical practice guidelines.
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Affiliation(s)
- Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York.
| | - Antonino Di Franco
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York
| | - Eloisa Arbustini
- Transplant Research Area and Centre for Inherited Cardiovascular Diseases, Scientific Department, IRCCS and Polyclinic San Matteo Foundation, Pavia, Italy
| | - Emile Bacha
- Division of Cardiac, Thoracic, and Vascular Surgery, Columbia University Medical Center/New York-Presbyterian Hospital, New York, New York
| | - Eric R Bates
- Cardiovascular Center, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Duke E Cameron
- Division of Cardiac Surgery, Corrigan Minehan Heart Center, Massachusetts General Hospital, Boston, Massachusetts
| | - Davide Cao
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York; Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Tirone E David
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Ruggero De Paulis
- Department of Cardiac Surgery, European Hospital, Rome, Italy; UniCamillus University, Rome, Italy
| | - Ismail El-Hamamsy
- Department of Cardiovascular Surgery, Mount Sinai Hospital and Icahn School of Medicine at Mount Sinai, New York, New York
| | - Kanwal M Farooqi
- Division of Pediatric Cardiology, New York-Presbyterian, Columbia University Irving Medical Center, New York, New York
| | - Leonard N Girardi
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York
| | - Christoph Gräni
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jonathan D Kochav
- Division of Cardiology, Columbia University Irving Medical Center, New York, New York
| | - Silvana Molossi
- Division of Pediatric Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - John D Puskas
- Department of Cardiovascular Surgery, Mount Sinai Hospital and Icahn School of Medicine at Mount Sinai, New York, New York
| | - Sunil V Rao
- Division of Interventional Cardiology, NYU Langone Health, New York, New York
| | - Sigrid Sandner
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - James Tatoulis
- Department of Cardiothoracic Surgery, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia
| | - Quynh A Truong
- Department of Radiology, New York Presbyterian, Weill Cornell Medicine, New York, New York
| | - Jonathan W Weinsaft
- Greenberg Cardiology Division, Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Daniel Zimpfer
- Division of Cardiac Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
| | - Carlos M Mery
- Texas Center for Pediatric and Congenital Heart Disease, Dell Medical School at The University of Texas at Austin/Dell Children's Medical Center, Austin, Texas
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4
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Gaudino M, Di Franco A, Arbustini E, Bacha E, Bates ER, Cameron DE, Cao D, David TE, De Paulis R, El-Hamamsy I, Farooqi KM, Girardi LN, Gräni C, Kochav JD, Molossi S, Puskas JD, Rao SV, Sandner S, Tatoulis J, Truong QA, Weinsaft JW, Zimpfer D, Mery CM. Management of Adults With Anomalous Aortic Origin of the Coronary Arteries: State-of-the-Art Review. J Am Coll Cardiol 2023; 82:2034-2053. [PMID: 37855757 DOI: 10.1016/j.jacc.2023.08.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 08/07/2023] [Accepted: 08/16/2023] [Indexed: 10/20/2023]
Abstract
As a result of increasing adoption of imaging screening, the number of adult patients with a diagnosis of anomalous aortic origin of the coronary arteries (AAOCA) has grown in recent years. Existing guidelines provide a framework for management and treatment, but patients with AAOCA present with a wide range of anomalies and symptoms that make general recommendations of limited applicability. In particular, a large spectrum of interventions can be used for treatment, and there is no consensus on the optimal approach to be used. In this paper, a multidisciplinary group of clinical and interventional cardiologists and cardiac surgeons performed a systematic review and critical evaluation of the available evidence on the interventional treatment of AAOCA in adult patients. Using a structured Delphi process, the group agreed on expert recommendations that are intended to complement existing clinical practice guidelines.
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Affiliation(s)
- Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA.
| | - Antonino Di Franco
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Eloisa Arbustini
- Transplant Research Area and Centre for Inherited Cardiovascular Diseases, Scientific Department, IRCCS and Polyclinic San Matteo Foundation, Pavia, Italy
| | - Emile Bacha
- Division of Cardiac, Thoracic, and Vascular Surgery, Columbia University Medical Center/New York-Presbyterian Hospital, New York, New York, USA
| | - Eric R Bates
- Cardiovascular Center, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Duke E Cameron
- Division of Cardiac Surgery, Corrigan Minehan Heart Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Davide Cao
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Tirone E David
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Ruggero De Paulis
- Department of Cardiac Surgery, European Hospital, Rome, Italy; UniCamillus University, Rome, Italy
| | - Ismail El-Hamamsy
- Department of Cardiovascular Surgery, Mount Sinai Hospital and Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Kanwal M Farooqi
- Division of Pediatric Cardiology, New York-Presbyterian, Columbia University Irving Medical Center, New York, New York, USA
| | - Leonard N Girardi
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Christoph Gräni
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jonathan D Kochav
- Division of Cardiology, Columbia University Irving Medical Center, New York, New York, USA
| | - Silvana Molossi
- Division of Pediatric Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - John D Puskas
- Department of Cardiovascular Surgery, Mount Sinai Hospital and Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Sunil V Rao
- Division of Interventional Cardiology, NYU Langone Health, New York, New York, USA
| | - Sigrid Sandner
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - James Tatoulis
- Department of Cardiothoracic Surgery, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia
| | - Quynh A Truong
- Department of Radiology, New York Presbyterian, Weill Cornell Medicine, New York, New York, USA
| | - Jonathan W Weinsaft
- Greenberg Cardiology Division, Department of Medicine, Weill Cornell Medical College, New York, New York, USA
| | - Daniel Zimpfer
- Division of Cardiac Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
| | - Carlos M Mery
- Texas Center for Pediatric and Congenital Heart Disease, Dell Medical School at The University of Texas at Austin/Dell Children's Medical Center, Austin, Texas, USA
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5
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Bigler MR, Gräni C. Editorial commentary: To screen or not to screen - and other pending questions within the enigma of coronary artery anomalies. Trends Cardiovasc Med 2023; 33:529-530. [PMID: 35690297 DOI: 10.1016/j.tcm.2022.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Accepted: 06/04/2022] [Indexed: 10/18/2022]
Affiliation(s)
- Marius Reto Bigler
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Christoph Gräni
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
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6
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Gräni C, Bigler MR, Kwong RY. Noninvasive Multimodality Imaging for the Assessment of Anomalous Coronary Artery. Curr Cardiol Rep 2023; 25:1233-1246. [PMID: 37851270 DOI: 10.1007/s11886-023-01948-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/19/2023] [Indexed: 10/19/2023]
Abstract
PURPOSE OF REVIEW Anomalous aortic origin of a coronary artery (AAOCA) is a rare congenital coronary anomaly with the potential to cause myocardial ischemia and adverse cardiac events. The presence of AAOCA anatomy itself does not necessarily implicate a need for revascularization. Therefore, the purpose of this review is to assess how noninvasive comprehensive anatomic- and physiologic evaluation may guide patient management. RECENT FINDINGS The assessment of AAOCA includes an accurate description of the anomalous origin/vessel course including anatomical high-risk features such as a slit-like ostium, proximal narrowing, elliptic vessel shape, acute take-off angle, intramural course, and possible concomitant coronary atherosclerosis and hemodynamics. Various cardiac imaging modalities offer unique advantages and capabilities in visualizing these anatomical and functional aspects of AAOCA. This review explored the role of noninvasive multimodality imaging in the characterization of AAOCA by highlighting the strengths, limitations, and potential applications of the current different cardiac imaging methods, with a focus on the pathophysiology of myocardial ischemia and stress testing protocols.
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Affiliation(s)
- Christoph Gräni
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Marius R Bigler
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Raymond Y Kwong
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA.
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7
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Li L, Ding W, Huang L, Zhuang X, Grau V. Multi-modality cardiac image computing: A survey. Med Image Anal 2023; 88:102869. [PMID: 37384950 DOI: 10.1016/j.media.2023.102869] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 05/01/2023] [Accepted: 06/12/2023] [Indexed: 07/01/2023]
Abstract
Multi-modality cardiac imaging plays a key role in the management of patients with cardiovascular diseases. It allows a combination of complementary anatomical, morphological and functional information, increases diagnosis accuracy, and improves the efficacy of cardiovascular interventions and clinical outcomes. Fully-automated processing and quantitative analysis of multi-modality cardiac images could have a direct impact on clinical research and evidence-based patient management. However, these require overcoming significant challenges including inter-modality misalignment and finding optimal methods to integrate information from different modalities. This paper aims to provide a comprehensive review of multi-modality imaging in cardiology, the computing methods, the validation strategies, the related clinical workflows and future perspectives. For the computing methodologies, we have a favored focus on the three tasks, i.e., registration, fusion and segmentation, which generally involve multi-modality imaging data, either combining information from different modalities or transferring information across modalities. The review highlights that multi-modality cardiac imaging data has the potential of wide applicability in the clinic, such as trans-aortic valve implantation guidance, myocardial viability assessment, and catheter ablation therapy and its patient selection. Nevertheless, many challenges remain unsolved, such as missing modality, modality selection, combination of imaging and non-imaging data, and uniform analysis and representation of different modalities. There is also work to do in defining how the well-developed techniques fit in clinical workflows and how much additional and relevant information they introduce. These problems are likely to continue to be an active field of research and the questions to be answered in the future.
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Affiliation(s)
- Lei Li
- Department of Engineering Science, University of Oxford, Oxford, UK.
| | - Wangbin Ding
- College of Physics and Information Engineering, Fuzhou University, Fuzhou, China
| | - Liqin Huang
- College of Physics and Information Engineering, Fuzhou University, Fuzhou, China
| | - Xiahai Zhuang
- School of Data Science, Fudan University, Shanghai, China
| | - Vicente Grau
- Department of Engineering Science, University of Oxford, Oxford, UK
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Lima BB, Cuddy SAM. Myocardial perfusion imaging in anomalous coronary arteries: do we know who to refer for cardiac surgery? J Nucl Cardiol 2023; 30:790-791. [PMID: 36369626 DOI: 10.1007/s12350-022-03127-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 09/22/2022] [Indexed: 11/13/2022]
Affiliation(s)
- Bruno B Lima
- Division of Cardiovascular Imaging, Department of Radiology, Brigham and Women's Hospital, 15 Francis Street, Boston, MA, 02116, USA
| | - Sarah A M Cuddy
- Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, 15 Francis Street, Boston, MA, 02116, USA.
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Agrawal H, Lamari-Fisher A, Hasbani K, Philip S, Fraser CD, Mery CM. Decision making in anomalous aortic origin of a coronary artery. Expert Rev Cardiovasc Ther 2023; 21:177-191. [PMID: 36846957 DOI: 10.1080/14779072.2023.2184799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
INTRODUCTION There are many uncertainties surrounding anomalous aortic origin of a coronary artery (AAOCA) including the pathophysiology of sudden cardiac death, how to best risk stratify patients, how to best evaluate patients, who would benefit from exercise restriction, who should undergo surgical intervention, and which operation to perform. AREAS COVERED The goal of this review is to provide a comprehensive but succinct overview of AAOCA to help clinicians with the difficult task of navigating optimal evaluation and treatment of an individual patient with AAOCA. EXPERT OPINION Beginning in year 2012, some of our authors proposed an integrated, multi-disciplinary working group which has become the standard management strategy for patients diagnosed with AAOCA. A multi-disciplinary team with a focus on shared decision-making with the patients/families is likely necessary to optimize outcomes. Long-term follow-up and research are needed to improve our understanding of AAOCA.
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Affiliation(s)
- Hitesh Agrawal
- Department of Pediatrics, Texas Center for Pediatric and Congenital Heart Disease, University of Texas Dell Medical School/Dell Children's Medical Center, Austin, TX, USA
| | - Alexandra Lamari-Fisher
- Department of Pediatrics, Texas Center for Pediatric and Congenital Heart Disease, University of Texas Dell Medical School/Dell Children's Medical Center, Austin, TX, USA
| | - Keren Hasbani
- Department of Pediatrics, Texas Center for Pediatric and Congenital Heart Disease, University of Texas Dell Medical School/Dell Children's Medical Center, Austin, TX, USA
| | - Stephanie Philip
- Department of Pediatrics, Texas Center for Pediatric and Congenital Heart Disease, University of Texas Dell Medical School/Dell Children's Medical Center, Austin, TX, USA
| | - Charles D Fraser
- Department of Pediatrics, Texas Center for Pediatric and Congenital Heart Disease, University of Texas Dell Medical School/Dell Children's Medical Center, Austin, TX, USA
| | - Carlos M Mery
- Department of Pediatrics, Texas Center for Pediatric and Congenital Heart Disease, University of Texas Dell Medical School/Dell Children's Medical Center, Austin, TX, USA
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Bigler MR, Kadner A, Räber L, Ashraf A, Windecker S, Siepe M, Padalino MA, Gräni C. Therapeutic Management of Anomalous Coronary Arteries Originating From the Opposite Sinus of Valsalva: Current Evidence, Proposed Approach, and the Unknowing. J Am Heart Assoc 2022; 11:e027098. [PMID: 36205254 DOI: 10.1161/jaha.122.027098] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Anomalous coronary arteries originating from the opposite sinus of Valsalva (ACAOS) are a challenge because of their various anatomic and clinical presentation. Although the prevalence is low, the absolute numbers of detected ACAOS are increasing because of the growing use of noninvasive anatomical imaging for ruling out coronary artery disease. As evidence-based guidelines are lacking, treating physicians are left in uncertainty for the optimal management of such patients. The sole presence of ACAOS does not justify surgical correction, and therefore a thorough anatomic and hemodynamic assessment is warranted. Invasive and noninvasive multimodality imaging provides information to the clinical question whether the presence of ACAOS is an innocent coincidental finding, is responsible for the patient's symptoms, or even might be a risk for sudden cardiac death. Based on recent clinical data, focusing on the pathophysiology of patients with ACAOS, myocardial ischemia is dependent on both the extent of fixed and dynamic components, represented by anatomic high-risk features. These varying combinations should be considered individually in the decision making for the different therapeutic options. This state-of-the-art review focuses on the advantages and limitations of the common contemporary surgical, interventional, and medical therapy with regard to the anatomy and pathophysiology of ACAOS. Further, we propose a therapeutic management algorithm based on current evidence on multimodality invasive and noninvasive imaging findings and highlight remaining gaps of knowledge.
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Affiliation(s)
- Marius Reto Bigler
- Department of Cardiology Inselspital, Bern University Hospital, University of Bern Bern Switzerland
| | - Alexander Kadner
- Centre for Congenital Heart Disease, Department of Cardiovascular Surgery Inselspital Bern Switzerland
| | - Lorenz Räber
- Department of Cardiology Inselspital, Bern University Hospital, University of Bern Bern Switzerland
| | - Afreed Ashraf
- Department of Cardiology Inselspital, Bern University Hospital, University of Bern Bern Switzerland
| | - Stephan Windecker
- Department of Cardiology Inselspital, Bern University Hospital, University of Bern Bern Switzerland
| | - Matthias Siepe
- Centre for Congenital Heart Disease, Department of Cardiovascular Surgery Inselspital Bern Switzerland
| | - Massimo Antonio Padalino
- Section of Pediatric and Congenital Cardiac Surgery, Department of Cardio-Thoracic and Vascular Sciences, and Public Health University of Padova, Medical School Padova Italy
| | - Christoph Gräni
- Department of Cardiology Inselspital, Bern University Hospital, University of Bern Bern Switzerland
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Gräni C, Padalino MA. Editorial: Coronary Artery Anomalies: A 2020 Review. Front Cardiovasc Med 2022; 9:776951. [PMID: 35224033 PMCID: PMC8866643 DOI: 10.3389/fcvm.2022.776951] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 01/12/2022] [Indexed: 11/13/2022] Open
Affiliation(s)
- Christoph Gräni
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- *Correspondence: Christoph Gräni
| | - Massimo Antonio Padalino
- Department of Cardiac, Thoracic and Vascular Sciences, and Public Health, University of Padova, Padua, Italy
- Massimo Antonio Padalino
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Abstract
Coronary artery anomalies (CAAs) are a group of congenital conditions characterized by abnormal origin or course of any of the 3 main epicardial coronary arteries. Although CAAs have been identified as a common underlying condition in young athletes with sudden cardiac death, the widespread use of invasive and noninvasive coronary imaging has led to increased recognition of CAAs among adults. CAAS are often discovered as an incidental finding during the diagnostic workup for ischemic heart disease. The clinical correlates and prognostic implication of CAAs remain poorly understood in this context, and guideline-recommended therapeutic choices are supported by a low level of scientific evidence. Several studies have examined whether assessment of CAA-related myocardial ischemia can improve risk stratification in these patients, suggesting that multimodality imaging and functional tests may be key in the management of CAAs. The aim of this review is to outline definitions, classification, and epidemiology of the most relevant CAAs, highlighting recent advances and the potential impact of multimodality evaluation, and to discuss current therapeutic opportunities.
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Affiliation(s)
- Francesco Gentile
- Cardiology Division, Pisa University Hospital, Italy (F.G., V.C., R.D.C.)
| | | | - Raffaele De Caterina
- Cardiology Division, Pisa University Hospital, Italy (F.G., V.C., R.D.C.).,Fondazione Villa Serena per la Ricerca, Città Sant'Angelo, Pescara, Italy (R.D.C.)
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Bigler MR, Huber AT, Räber L, Gräni C. A case report of a symptomatic right anomalous coronary artery with concomitant atherosclerotic disease: the benefit of a sequential comprehensive non-invasive and invasive diagnostic approach. EUROPEAN HEART JOURNAL-CASE REPORTS 2021; 5:ytab081. [PMID: 33718769 PMCID: PMC7939695 DOI: 10.1093/ehjcr/ytab081] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 12/04/2020] [Accepted: 02/04/2021] [Indexed: 11/13/2022]
Abstract
Background Anomalous aortic origin of a coronary artery (AAOCA) is a rare congenital disease associated with an increased risk of myocardial ischaemia, ventricular arrhythmias, and heart failure. Case summary A 75-year-old Caucasian man was referred for invasive coronary angiography (ICA) due to atypical chest pain. Invasive coronary angiography demonstrated non-significant atherosclerotic disease of the left coronary artery and an anomalous origin of the right coronary artery (RCA); without selective intubation. Coronary computed tomography angiography (CCTA) revealed a right-AAOCA with interarterial and intramural course, and a soft plaque in the distal RCA. Subsequent physical-stress single-photon emissions computed tomography (SPECT) showed exercise-induced inferoapical myocardial ischaemia, giving a Class IC level of evidence for surgical correction of the AAOCA. Repeated ICA with selective R-AAOCA intubation confirmed an 80% distal atherosclerotic stenosis, which was treated with direct stenting. Subsequent invasive physiologic evaluation under maximal dobutamine-volume challenge (gradually increasing dose of dobutamine max. 40 μg/kg per body weight/min, 3000 mL ringer lactate and 1 mg atropine was given until the patient reached a maximum of 145 b.p.m.), revealed a haemodynamically non-relevant anomalous segment with a fractional flow reserve (FFR) of 0.91. A follow-up SPECT was normal, and the patient was completely symptom-free at 1 month. Discussion We present the sequential diagnostic approach in a symptomatic patient with a right anomalous coronary artery and concomitant atherosclerotic disease. Using this approach, the patient could be deferred from guideline recommended open-heart surgery of the AAOCA, as direct invasive dobutamine/volume FFR revealed haemodynamic non-relevance of the anomalous segment after stenting the concomitant atherosclerotic stenosis in the distal segment within the same coronary artery.
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Affiliation(s)
- Marius Reto Bigler
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, CH-3010 Bern, Switzerland
| | - Adrian Thomas Huber
- Department of Diagnostic, Interventional and Paediatric Radiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Lorenz Räber
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, CH-3010 Bern, Switzerland
| | - Christoph Gräni
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, CH-3010 Bern, Switzerland
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Bigler MR, Ashraf A, Seiler C, Praz F, Ueki Y, Windecker S, Kadner A, Räber L, Gräni C. Hemodynamic Relevance of Anomalous Coronary Arteries Originating From the Opposite Sinus of Valsalva-In Search of the Evidence. Front Cardiovasc Med 2021; 7:591326. [PMID: 33553251 PMCID: PMC7859106 DOI: 10.3389/fcvm.2020.591326] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 12/23/2020] [Indexed: 12/16/2022] Open
Abstract
Coronary artery anomalies (CAA) represent a heterogeneous group of congenital disorders of the arterial coronary circulation, defined by an anomalous origin of the coronary ostium and/or vessel course. Of particular interest are anomalous coronary arteries originating from the opposite sinus of Valsalva (ACAOS). The interarterial variants (with the anomalous vessel situated between the great arteries) are historically called "malignant," based on an anticipated higher risk for myocardial ischemia and sudden cardiac death (SCD), especially affecting young patients during strenuous physical activity. However, the interarterial course itself may not be the predominant cause of ischemia, but rather represents a surrogate for other ischemia-associated anatomical high-risk features. As the exact pathophysiology of ACAOS is not well-understood, there is a lack of evidence-based guidelines addressing optimal diagnostic work-up, downstream testing, sports counseling, and therapeutic options in patients with ACAOS. Therefore, treating physicians are often left with uncertainty regarding the clinical management of affected patients. This review focuses on the pathophysiologic consequences of ACAOS on myocardial ischemia and discusses the concept of the interplay between fixed and dynamic coronary stenosis. Further, we discuss the advantages and limitations of the different diagnostic modalities and give an outlook by highlighting the gaps of knowledge in the assessment of such anomalies.
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Affiliation(s)
- Marius Reto Bigler
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Afreed Ashraf
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Christian Seiler
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Fabien Praz
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Yasushi Ueki
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Stephan Windecker
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Alexander Kadner
- Department of Cardiovascular Surgery, Centre for Congenital Heart Disease, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Lorenz Räber
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Christoph Gräni
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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15
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EANM procedural guidelines for PET/CT quantitative myocardial perfusion imaging. Eur J Nucl Med Mol Imaging 2020; 48:1040-1069. [PMID: 33135093 PMCID: PMC7603916 DOI: 10.1007/s00259-020-05046-9] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 09/17/2020] [Indexed: 12/19/2022]
Abstract
The use of cardiac PET, and in particular of quantitative myocardial perfusion PET, has been growing during the last years, because scanners are becoming widely available and because several studies have convincingly demonstrated the advantages of this imaging approach. Therefore, there is a need of determining the procedural modalities for performing high-quality studies and obtaining from this demanding technique the most in terms of both measurement reliability and clinical data. Although the field is rapidly evolving, with progresses in hardware and software, and the near perspective of new tracers, the EANM Cardiovascular Committee found it reasonable and useful to expose in an updated text the state of the art of quantitative myocardial perfusion PET, in order to establish an effective use of this modality and to help implementing it on a wider basis. Together with the many steps necessary for the correct execution of quantitative measurements, the importance of a multiparametric approach and of a comprehensive and clinically useful report have been stressed.
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Gräni C, Kaufmann PA, Windecker S, Buechel RR. Diagnosis and Management of Anomalous Coronary Arteries with a Malignant Course. ACTA ACUST UNITED AC 2019; 14:83-88. [PMID: 31178934 PMCID: PMC6545977 DOI: 10.15420/icr.2019.1.1] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 03/11/2019] [Indexed: 12/26/2022]
Abstract
Although the prevalence of anomalous coronary artery from the opposite sinus (ACAOS) in the general population is low, more frequent use of invasive and non-invasive imaging to rule out coronary artery disease has seen an increase in absolute numbers of ACAOS. ACAOS are traditionally classified as malignant (with an interarterial course) and benign variants. Malignant variants have been recognised in autopsy studies to be an underlying cause of sudden cardiac death in young athletes. Conversely, it seems that older people with ACAOS are less predisposed to adverse cardiac events. Non-invasive anatomic imaging is complementary to invasive imaging and helps to further identify high-risk anatomic features. Using functional non-invasive perfusion imaging can assess potential ischaemia induced by dynamic compression of malignant ACAOS. Information gained from clinical imaging guides the management of these patients.
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Affiliation(s)
- Christoph Gräni
- Department of Cardiology, Bern University Hospital Bern, Switzerland.,Department of Nuclear Medicine, University Hospital Zurich Zurich, Switzerland
| | - Philipp A Kaufmann
- Department of Nuclear Medicine, University Hospital Zurich Zurich, Switzerland
| | - Stephan Windecker
- Department of Cardiology, Bern University Hospital Bern, Switzerland
| | - Ronny R Buechel
- Department of Nuclear Medicine, University Hospital Zurich Zurich, Switzerland
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18
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The incremental clinical value of cardiac hybrid SPECT/CTA imaging in coronary artery disease. Nucl Med Commun 2018; 39:469-478. [PMID: 29652747 DOI: 10.1097/mnm.0000000000000838] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Coronary artery disease (CAD) is a major cause of death worldwide. It is significantly important to assess the coronary lesion and its pathophysiological relevance comprehensively. Coronary computed tomography angiography (CTA) or myocardial perfusion imaging alone suffers from some limitations in the evaluation of CAD. Through the integration and spatial colocalization of complementary morphological and functional information, the results of published hybrid single-photon emission computed tomography (SPECT)/CTA studies in patients with CAD are promising for detecting functionally relevant coronary artery lesion and evaluating the relationship between diseased coronary artery, coronary artery anomaly, myocardial bridging, or coronary calcification and myocardial ischemia. Compared with other diagnostic procedures, such as CTA, myocardial perfusion imaging alone, and side-by-side SPECT-CTA analysis, SPECT/CTA imaging has incremental value in the evaluation of CAD. Hybrid SPECT/CTA imaging can provide the physicians with more clinical evidence that helps with the treatment strategy decision-making process, thus acting as a gatekeeper to reduce unnecessary invasive examinations and revascularization procedures. In addition, follow-up SPECT/CTA fusion imaging plays a role in predicting prognosis by displaying clearly the relationship between postoperative vessel and myocardial blood supply. However, several limitations should be considered, including the increased radiation exposure, the limited number of patients, and the lack of a uniform gold standard. More data are needed to better specify the role of hybrid SPECT/CTA imaging in the management of CAD.
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Green T, Crilley J. Endocarditis and coronary artery fistula: a case report. EUROPEAN HEART JOURNAL-CASE REPORTS 2018; 2:yty023. [PMID: 31020102 PMCID: PMC6426014 DOI: 10.1093/ehjcr/yty023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/14/2017] [Accepted: 02/11/2018] [Indexed: 12/25/2022]
Abstract
Introduction Coronary artery fistulae are rare abnormal congenital communications between a coronary artery and a cardiac chamber or great vessel. The majority of adult patients are asymptomatic, and it is most commonly discovered incidentally on coronary angiography. Case Presentation We present the case of a 50-year-old woman, with a known fistula connecting the right coronary artery (RCA) and right atrium (RA), presenting with aortic valve endocarditis and pulmonary emboli. We detail the presentation and echocardiographic findings of aortic valve endocarditis with extension of the vegetation into the RA via the giant RCA fistula. We describe the clinical course including initial therapy, embolization of the right atrial vegetation to the lungs, and ultimately successful surgical correction after prolonged antibiotic therapy. Discussion Patients with coronary artery fistulae are susceptible to potentially serious complications including myocardial ischaemia, shunting and in this case infective endocarditis. We review the literature and discuss timings for corrective intervention.
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Gräni C, Benz D, Steffen D, Giannopoulos A, Messerli M, Pazhenkottil A, Gaemperli O, Gebhard C, Schmied C, Kaufmann P, Buechel R. Sports Behavior in Middle-Aged Individuals with Anomalous Coronary Artery from the Opposite Sinus of Valsalva. Cardiology 2018; 139:222-230. [DOI: 10.1159/000486707] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Accepted: 01/08/2018] [Indexed: 01/09/2023]
Abstract
Objectives: Recommendations regarding sports restriction are lacking for middle-aged athletes with anomalous coronary arteries originating from the opposite sinus of Valsalva (ACAOS). Methods: Sixty-three patients with ACAOS were subdivided into ACAOS with (n = 38) or without (n = 25) an interarterial course (IAC). Sports behavior, either competitive (COMP) or recreational (REC), was evaluated at the time of diagnosis and after a median follow-up of 4.2 years. Results: Mean age was 56 ± 11 years and 48 (76.2%) patients were engaged in sports. Three individuals (4.8%) were surgically corrected after diagnosis. Thirty-eight (60.3%) patients were aware of their diagnosis at follow-up and 12 (19.0%) were counseled by their physician about sports restrictions. Sports behavior at the time of diagnosis and at follow-up did not differ significantly, neither in patients engaged in COMP (17.5 vs. 12.7%, p = 0.619) nor those engaged in REC (58.7 vs. 61.9%, p = 0.856). Sport-related symptoms were not significantly different between ACAOS patients with and without IAC. No athlete had died at follow-up. Conclusions: The majority of middle-aged individuals with ACAOS were involved in sports activities at the time of diagnosis and at follow-up. Awareness and counseling about ACAOS diagnosis had no significant effect on sports behavior. IAC did not have an impact on sport-related symptoms, and outcomes were favorable in all athletes, regardless of surgical correction.
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Giannopoulos AA, Gaemperli O. Hybrid Imaging in Ischemic Heart Disease. ACTA ACUST UNITED AC 2018; 71:382-390. [PMID: 29329818 DOI: 10.1016/j.rec.2017.11.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Accepted: 11/22/2017] [Indexed: 01/21/2023]
Abstract
Hybrid imaging for ischemic heart disease refers to the fusion of information from a single or usually from multiple cardiovascular imaging modalities enabling synergistic assessment of the presence, the extent, and the severity of coronary atherosclerotic disease along with the hemodynamic significance of lesions and/or with evaluation of the myocardial function. A combination of coronary computed tomography angiography with myocardial perfusion imaging, such as single-photon emission computed tomography and positron emission tomography, has been adopted in several centers and implemented in international coronary artery disease management guidelines. Interest has increased in novel hybrid methods including coronary computed tomography angiography-derived fractional flow reserve and computed tomography perfusion and these techniques hold promise for the imminent diagnostic and management approaches of patients with coronary artery disease. In this review, we discuss the currently available hybrid noninvasive imaging modalities used in clinical practice, research approaches, and exciting potential future technological developments.
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Affiliation(s)
- Andreas A Giannopoulos
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Zurich, Switzerland
| | - Oliver Gaemperli
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Zurich, Switzerland.
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Gräni C, Buechel RR, Kaufmann PA, Kwong RY. Multimodality Imaging in Individuals With Anomalous Coronary Arteries. JACC Cardiovasc Imaging 2017; 10:471-481. [DOI: 10.1016/j.jcmg.2017.02.004] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Revised: 02/08/2017] [Accepted: 02/15/2017] [Indexed: 01/02/2023]
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Bouma BJ, Mulder BJ. Changing Landscape of Congenital Heart Disease. Circ Res 2017; 120:908-922. [DOI: 10.1161/circresaha.116.309302] [Citation(s) in RCA: 129] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Revised: 01/13/2017] [Accepted: 01/13/2017] [Indexed: 01/23/2023]
Abstract
Congenital heart disease is the most frequently occurring congenital disorder affecting ≈0.8% of live births. Thanks to great efforts and technical improvements, including the development of cardiopulmonary bypass in the 1950s, large-scale repair in these patients became possible, with subsequent dramatic reduction in morbidity and mortality. The ongoing search for progress and the growing understanding of the cardiovascular system and its pathophysiology refined all aspects of care for these patients. As a consequence, survival further increased over the past decades, and a new group of patients, those who survived congenital heart disease into adulthood, emerged. However, a large range of complications raised at the horizon as arrhythmias, endocarditis, pulmonary hypertension, and heart failure, and the need for additional treatment became clear. Technical solutions were sought in perfection and creation of new surgical techniques by developing catheter-based interventions, with elimination of open heart surgery and new electronic devices enabling, for example, multisite pacing and implantation of internal cardiac defibrillators to prevent sudden death. Over time, many pharmaceutical studies were conducted, changing clinical treatment slowly toward evidence-based care, although results were often limited by low numbers and clinical heterogeneity. More attention has been given to secondary issues like sports participation, pregnancy, work, and social-related difficulties. The relevance of these issues was already recognized in the 1970s when the need for specialized centers with multidisciplinary teams was proclaimed. Finally, research has become incorporated in care. Results of intervention studies and registries increased the knowledge on epidemiology of adults with congenital heart disease and their complications during life, and at the end, several guidelines became easily accessible, guiding physicians to deliver care appropriately. Over the past decades, the landscape of adult congenital heart disease has changed dramatically, which has to be continued in the future.
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Affiliation(s)
- Berto J. Bouma
- From the Department of Cardiology, Academic Medical Center, Amsterdam, The Netherlands
| | - Barbara J.M. Mulder
- From the Department of Cardiology, Academic Medical Center, Amsterdam, The Netherlands
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