Cardiac stress MRI evaluation of anomalous aortic origin of a coronary artery

Advice to Young Athletes With Anomalous Aortic Origin of a Coronary Artery With and Without Surgery

Congenital coronary artery anomalies remain a leading cause of sudden cardiac death in the young. Within these, anomalous aortic origin of a coronary artery represents the largest group, with anomalies of the left coronary artery carrying higher risk for sudden cardiac arrest and clinical manifestations of myocardial ischemia. In contrast, anomalies of origin of the right coronary artery are more common and generally have a more benign clinical course, though rarely also associated with sudden events and myocardial ischemia. Risk stratification to guide management decisions remains to be well defined, though substantial advances have occurred in the last few years, with assessment of myocardial perfusion under provocative stress being an integral part of the evaluation in the young. Discussion and counseling on exercise behavior is essential to foster healthy lifestyle for these patients, acknowledging shared decision-making should be practiced in lieu of many unanswered questions as to outcomes long-term.

Imaging of common coronary artery anomalies and imaging features important for clinical decision-making

Anomalous coronary arteries are associated with sudden cardiac death, although only in a relatively small percentage. Although this has been a field of study for years and there are many ongoing studies of larger patient cohorts and longer term follow-up, important questions remain at present in clinical decision-making, particularly whether or not to have surgery. Advanced imaging techniques including coronary computed tomography (CT) and cardiac magnetic resonance (MR) play an important role in the workup of patients with known or suspected anomalies including delineating origin and course as well as defining presence of high-risk imaging features. Multidisciplinary decision-making is important when considering whether patients might need to undergo surgery. This review will describe types of anomalies, imaging techniques, and features as well as types of surgeries and postoperative imaging with highlights of imaging and surgical literature and several case examples.

Anomalous Coronary Arteries: A State-of-the-Art Approach

Congenital coronary anomalies are not an infrequent occurrence and their clinical presentation typically occurs during early years, though may be manifested only in adulthood. In the setting of anomalous aortic origin of a coronary artery, this is particularly concerning as it inflicts sudden loss of healthy young lives. Risk stratification remains a challenge and so does the best management decision-making in these patients, particularly if asymptomatic. Standardized approach to evaluation and management, with careful data collection and collaboration among centers, will likely impact future outcomes in this patient population, thus allowing for exercise participation and healthier lives.

Anomalous Coronary Arteries: A State-of-the-Art Approach

Congenital coronary anomalies are not an infrequent occurrence and their clinical presentation typically occurs during early years, though may be manifested only in adulthood. In the setting of anomalous aortic origin of a coronary artery, this is particularly concerning as it inflicts sudden loss of healthy young lives. Risk stratification remains a challenge and so does the best management decision-making in these patients, particularly if asymptomatic. Standardized approach to evaluation and management, with careful data collection and collaboration among centers, will likely impact future outcomes in this patient population, thus allowing for exercise participation and healthier lives.

Coronary Artery Anomalies - State of the Art Review

Coronary artery anomalies (CAAs) comprise a wide spectrum of anatomic entities, with diverse clinical phenotypes. We present a case of an anomalous right coronary artery arising from the left aortic sinus with an interarterial course, a potentially fatal condition that can precipitate ischemia and sudden cardiac death. CAAs are increasingly detected in adults, mostly as incidental findings in the course of cardiac evaluation. This is due to the expanding use of invasive and noninvasive cardiac imaging, usually in the work-up for possible CAD. The prognostic implications of CAAs in this group of patients remain unclear. In AAOCA patients, appropriate work-up with anatomical and functional imaging should be performed for risk stratification. An individualized approach to management should be adopted, considering symptoms, age, sporting activities and the presence of high-risk anatomical features and physiologic consequences (such as ischemia, myocardial fibrosis, or cardiac arrhythmias) detected on multimodality imaging or other functional cardiac investigations. This comprehensive and up to date review seeks to crystallize current data in the recent literature, and proposes a clinical management algorithm for the clinician faced with the conundrum of managing such conditions.

Spectrum of the anomalous origin of the coronary arteries

The anomalous origin of the coronary arteries (AOCA) has several patterns. Most are functional and asymptomatic. However, some are associated with persistent chest pain and sudden cardiac death. Multiple imaging techniques are available for the assessment of AOCA. We present a report of 4 cases with AOCA, including the anomalous aortic origin of a coronary artery (AAOCA) of the right coronary artery, AAOCA of the circumflex artery, AAOCA of the left anterior descending artery, and AAOCA of the circumflex artery with retroaortic trajectory, in which the clinical manifestations throughout the cases are discussed, highlighting the similarity among patients despite having different patterns. Multiple imaging techniques are indispensable for assessing AOCA, where transthoracic echocardiogram is the first-line study, and cardiac computed tomography provides detailed cardiac and coronary anatomy.

Congenital coronary artery anomalies in sports medicine. Why to know them

The anomalous origin of a coronary artery (AOCA) is a challenging topic, due to its rarity, the complexity of the pathophysiological aspects, the clinical presentation (often silent), the difficulty of diagnosis, and the potential risk of causing acute cardiovascular events up to sudden cardiac death, particularly when triggered by heavy physical exercise or sport practice. Increasing interest in sport medical literature is being given to this topic. This paper reviews current knowledge of AOCAs in the specific context of the athletic setting addressing epidemiological and pathophysiological aspects, diagnostic work-up, sports participation, individual risk assessment, therapeutic options, and return to play decision after surgery.

Clinical Presentation and Medium-Term Outcomes of Children With Anomalous Aortic Origin of the Left Coronary Artery: High-Risk Features Beyond Interarterial Course

BACKGROUND

Anomalous aortic origin of the left coronary artery (AAOLCA) confers a rare, but significant, risk of sudden cardiac death in children. Surgery is recommended for interarterial AAOLCA, and other subtypes considered benign. We aimed to determine the clinical characteristics and outcomes of 3 AAOLCA subtypes.

METHODS

All patients with AAOLCA <21 years old were prospectively enrolled (December 2012-November 2020), including group 1: AAOLCA from the right aortic sinus with interarterial course, group 2: AAOLCA from the right aortic sinus with intraseptal course, and group 3: AAOLCA with a juxtacommissural origin between the left and noncoronary aortic sinus. Anatomic details were assessed using computed tomography angiography. Provocative stress testing (exercise stress testing and stress perfusion imaging) was performed in patients >8 years old or younger if concerning symptoms. Surgery was recommended for group 1 and in select cases in group 2 and group 3.

RESULTS

We enrolled 56 patients (64% males) with AAOLCA (group 1, 27; group 2, 20; group 3, 9) at median age of 12 years (interquartile range, 6-15). Intramural course was common in group 1 (93%) compared with group 3 (56%) and group 2 (10%). Seven (13%) presented with aborted sudden cardiac death (group 1, 6/27; group 3, 1/9); 1 (group 3) with cardiogenic shock. Fourteen/42 (33%) had inducible ischemia on provocative testing (group 1, 32%; group 2, 38%; group 3, 29%). Surgery was recommended in 31/56 (56%) patients (group 1, 93%; group 2, 10%; and group 3, 44%). Surgery was performed in 25 patients at a median age 12 (interquartile range, 7-15) years; all have been asymptomatic and free from exercise restrictions at median follow-up of 4 (interquartile range, 1.4-6.3) years.

CONCLUSIONS

Inducible ischemia was noted in all 3 AAOLCA subtypes while most aborted sudden cardiac deaths occurred in interarterial AAOLCA (group 1). Aborted sudden cardiac death and cardiogenic shock may occur in AAOLCA with left/nonjuxtacommissural origin and intramural course, thus also deemed high-risk. A systematic approach is essential to adequately risk stratify this population.

Is Exercise Stress Testing Useful for Risk Stratification in Anomalous Aortic Origin of a Coronary Artery?

Data on maximal exercise-stress-testing (m-EST) in anomalous-aortic-origin-of-coronary-arteries (AAOCA) is limited and correlation with stress perfusion imaging has not been demonstrated. AAOCA patients ≤20 years were prospectively enrolled from 6/2014-01/2020. A m-EST was defined as heart rate >85%ile on ECG-EST and respiratory-exchange-ratio ≥1.05 on cardiopulmonary-exercise-testing (CPET). Abnormal m-EST included significant ST-changes or high-grade arrhythmia, V̇O2max and/or O2 pulse <85% predicted, or abnormal O2 pulse curve. A (+) dobutamine-stress cardiac-magnetic-resonance-imaging (+DS-CMR) had findings of inducible-ischemia. Outcomes: (1) Differences in m-EST based on AAOCA-type; (2) Assuming DS-CMR as gold-standard for detection of inducible ischemia, determine agreement between m-EST and DS-CMR. A total of 155 AAOCA (right, AAORCA = 126; left, AAOLCA = 29) patients with a median (IQR) age of 13 (11-15) years were included; 63% were males and a m-EST was completed in 138 (89%). AAORCA and AAOLCA had similar demographic and m-EST characteristics, although AAOLCA had more frequently evidence of inducible ischemia on m-EST (P = 0.006) and DS-CMR (P = 0.007). Abnormal O2 pulse was significantly associated with +DS-CMR (OR 5.3, 95% CI 1.6-18,P = 0.005). Sensitivity was increased with addition of CPET to ECG-EST (to 58% from 19%). There was no agreement between m-EST and DS-CMR for detection of inducible ischemia. A m-EST has very low sensitivity for detection of inducible ischemia in AAOCA, and sensitivity is increased with addition of CPET. Stress perfusion abnormalities on DS-CMR were notconcordant with m-EST findings and adjunctive testing should be considered for clinical decision making in AAOCA.

Coronary Artery Anomalies

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.

Current Management of Anomalous Aortic Origin of a Coronary Artery: A Pan-Canadian Survey

Background:

Anomalous aortic origin of a coronary artery (AAOCA) is a significant cause of sudden cardiac death (SCD) in children and adolescents. The natural history of AAOCA and the pathophysiology of AAOCA-related SCD are poorly understood. Therefore, the evaluation and management of AAOCA remain controversial. This survey-based study aims to report the current AAOCA management tendencies in Canada.

Methods:

We built a 23-question survey on AAOCA. Questions pertained to patient presentation, investigations, morphology of the anomaly, management, and follow-up. We sent the survey to all the Canadian congenital cardiac surgeons, pediatric cardiologists, and adult congenital cardiologists. Data were anonymized and analysis was performed using descriptive statistics.

Results:

According to our survey participants (N = 47), patient age (94%) and amount of physical activity (60%) are the most influential factors when deciding whether to offer surgical correction. Aborted SCD, exercise-induced syncope, typical chest pain, and left jaw or arm pain are the most important clinical presentations indicating surgery. The most commonly used preoperative investigations are rest echocardiography (75%), electrocardiogram (68%), and exercise stress test (62%). Most respondents favor the unroofing procedure (78%) for surgical correction. For nonsurgical candidates, most physicians choose competitive exercise restriction (64%).

Conclusion:

We found a divergence between current practices and expert consensus guidelines regarding the treatment of asymptomatic left AAOCA with high-risk features. Our survey also revealed a lack of consensus among clinicians regarding the management of asymptomatic patients, very young patients, and those with right-sided AAOCA. Evidence-based criteria derived from sufficiently powered studies remain to be established to standardize AAOCA treatment.

Dobutamine stress cardiac MRI is safe and feasible in pediatric patients with anomalous aortic origin of a coronary artery (AAOCA)

BACKGROUND

Risk stratification in anomalous aortic origin of a coronary artery (AAOCA) is challenged by the lack of a reliable method to detect myocardial ischemia. We prospectively studied the safety and feasibility of Dobutamine stress-cardiac magnetic resonance (DSCMR), a test with excellent performance in adults, in pediatric patients with AAOCA.

METHODS

Consecutive DSCMR from 06/2014-12/2019 in patients≤20 years old with AAOCA were included. Hemodynamic response and major/minor events were recorded. Image quality and spatial/temporal resolution were evaluated. Rest and stress first-pass perfusion and wall motion abnormalities (WMA) were assessed. Inter-observer agreement was assessed using kappa coefficient.

RESULTS

A total of 224 DSCMR were performed in 182 patients with AAOCA at a median age of 14 years (IQR 12, 16) and median weight of 58.0 kg (IQR 43.3, 73.0). Examinations were completed in 221/224 (98.9%), all studies were diagnostic. Heart rate and blood pressure increased significantly from baseline (p < 0.001). No patient had major events and 28 (12.5%) had minor events. Inducible hypoperfusion was noted in 31/221 (14%), associated with WMA in 13/31 (42%). Inter-observer agreement for inducible hypoperfusion was very good (Κ = 0.87). Asymptomatic patients with inducible hypoperfusion are considered high-risk and those with a negative test are of standard risk.

CONCLUSIONS

DSCMR is feasible in pediatric patients with AAOCA to assess for inducible hypoperfusion and WMA. It can be performed safely with low incidence of major/minor events. Thus, DSCMR is potentially a valuable test for detection of myocardial ischemia and helpful in the management of this patient population.

Pharmacologic stress cardiovascular magnetic resonance in the pediatric population: A review of the literature, proposed protocol, and two examples in patients with Kawasaki disease

Pharmacologic stress cardiovascular magnetic resonance (PSCMR) is a well-established and reliable diagnostic tool for evaluation of coronary artery disease in the adult population. Stress imaging overall and PSCMR in particular is less utilized in the pediatric population with limited reported data. In this review, we highlight the potential use of PSCMR in specific pediatric cohorts with congenital and acquired heart disease, and we review the reported experience. A suggested protocol is presented in addition to two case examples of patients with Kawasaki disease where PSCMR aided decision making.

Management and Anesthetic Considerations for Patients With Anomalous Aortic Origin of a Coronary Artery

The term "coronary artery anomalies" encompasses a large and heterogeneous group of disorders that may affect origin, intrinsic anatomy, course, location, and termination of the coronary arteries. With these different anatomies, presentation, symptoms, and outcomes are heterogeneous as well. While significant efforts are directed toward improving diagnosis and risk-stratification, best evidence-guided practices remain in evolution. Data about anesthetic management of patients with coronary anomalies are lacking as well. This review aims to provide the anesthesiologist with a better understanding of an important subgroup of coronary artery anomalies: anomalous aortic origin of a coronary artery. We will discuss classification, pathophysiology, incidence, evaluation, management, and anesthetic implications of this potentially fatal disease group.