1
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de Lange C, Rodriguez CM, Martinez-Rios C, Lam CZ. Urgent and emergent pediatric cardiovascular imaging. Pediatr Radiol 2024:10.1007/s00247-024-05980-y. [PMID: 38967787 DOI: 10.1007/s00247-024-05980-y] [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] [Received: 04/29/2024] [Revised: 06/18/2024] [Accepted: 06/20/2024] [Indexed: 07/06/2024]
Abstract
The need for urgent or emergent cardiovascular imaging in children is rare when compared to adults. Patients may present from the neonatal period up to adolescence, and may require imaging for both traumatic and non-traumatic causes. In children, coronary pathology is rarely the cause of an emergency unlike in adults where it is the main cause. Radiology, including chest radiography and computed tomography in conjunction with echocardiography, often plays the most important role in the acute management of these patients. Magnetic resonance imaging can occasionally be useful and may be suitable in more subacute cases. Radiologists' knowledge of how to manage and interpret these acute conditions including knowing which imaging technique to use is fundamental to appropriate care. In this review, we will concentrate on the most common cardiovascular emergencies in the thoracic region, including thoracic traumatic and non-traumatic emergencies and pulmonary vascular emergencies, as well as acute clinical disorders as a consequence of primary and postoperative congenital heart disease. This review will cover situations where cardiovascular imaging may be acutely needed, and not strictly emergencies only. Imaging recommendations will be discussed according to the different clinical presentations and underlying pathology.
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Affiliation(s)
- Charlotte de Lange
- Department of Pediatric Radiology, Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Behandlingsvägen 7, 416 50, Gothenburg, Sweden.
- Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
| | | | - Claudia Martinez-Rios
- Department of Diagnostic and Interventional Radiology, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Medical Imaging, University of Toronto, Toronto, ON, Canada
| | - Christopher Z Lam
- Department of Diagnostic and Interventional Radiology, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Medical Imaging, University of Toronto, Toronto, ON, Canada
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2
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Maller VV, Johnson JN, Boston U, Knott-Craig C. Transseptal coronary artery-a pictorial review. Pediatr Radiol 2024; 54:1261-1269. [PMID: 38637337 PMCID: PMC11255081 DOI: 10.1007/s00247-024-05911-x] [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] [Received: 11/21/2023] [Revised: 03/08/2024] [Accepted: 03/15/2024] [Indexed: 04/20/2024]
Abstract
A transseptal coronary artery course, also known as a transconal course, is an anomalous course of the left main coronary artery (LMCA) or the left anterior descending artery (LAD) through the conal septal myocardium. The conal septal myocardium is the posterior wall of the right ventricular outflow tract (RVOT), acting as a dividing myocardial wall between the subaortic and subpulmonary outflow tracts. The initial segment of a transseptal coronary artery has an extraconal course between the aorta and the RVOT cranial to the true intramyocardial segment. The transseptal coronary artery then emerges out of the conal septal myocardium at the epicardial surface on the lateral aspect of the RVOT. Many consider the transseptal coronary artery to be a benign entity. However, there are few case reports of severe cardiac symptoms such as myocardial ischemia, arrhythmia, and even sudden cardiac deaths due to potential coronary artery compression in the systolic phase. In this article, we seek to describe the imaging findings of transseptal coronary artery course on coronary computed tomography angiography (CTA), discuss their clinical analysis, and briefly discuss the management of these lesions.
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Affiliation(s)
- Vijetha V Maller
- Department of Radiology, LeBonheur Children's Hospital, University of Tennessee Health Science Center, 848 Adams Avenue, Radiology G216, Memphis, TN, USA.
| | - Jason N Johnson
- Division of Pediatric Cardiology, Pediatrics, Heart institute, LeBonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Umar Boston
- Division of Pediatric Cardiothoracic Surgery, Department of Surgery, Heart Institute, LeBonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Christopher Knott-Craig
- Division of Pediatric Cardiothoracic Surgery, Department of Surgery, Heart Institute, LeBonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, TN, USA
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3
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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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4
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Molossi S, Doan T, Sachdeva S. Anomalous Coronary Arteries: A State-of-the-Art Approach. Card Electrophysiol Clin 2024; 16:51-69. [PMID: 38280814 DOI: 10.1016/j.ccep.2023.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2024]
Abstract
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.
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Affiliation(s)
- Silvana Molossi
- Coronary Artery Anomalies Program, Texas Children's Hospital, 6651 Main Street, MC E1920, Houston, TX 77030, USA; The Lillie Frank Abercrombie Section of Cardiology, Texas Children's Hospital, Baylor College of Medicine, 6651 Main Street, MC E1920, Houston, TX 77030, USA.
| | - Tam Doan
- Coronary Artery Anomalies Program, Texas Children's Hospital, 6651 Main Street, MC E1920, Houston, TX 77030, USA; The Lillie Frank Abercrombie Section of Cardiology, Texas Children's Hospital, Baylor College of Medicine, 6651 Main Street, MC E1920, Houston, TX 77030, USA
| | - Shagun Sachdeva
- Coronary Artery Anomalies Program, Texas Children's Hospital, 6651 Main Street, MC E1920, Houston, TX 77030, USA; The Lillie Frank Abercrombie Section of Cardiology, Texas Children's Hospital, Baylor College of Medicine, 6651 Main Street, MC E1920, Houston, TX 77030, USA
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5
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Doan TT, Bonilla-Ramirez C, Eilers L, Reaves-O'Neal D, Sachdeva S, Dolgner SJ, Masand PM, Gowda S, Qureshi AM, Binsalamah Z, Molossi S. Myocardial bridges in a pediatric population: Outcomes following a standardized approach. J Thorac Cardiovasc Surg 2024:S0022-5223(24)00003-5. [PMID: 38199293 DOI: 10.1016/j.jtcvs.2023.12.024] [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] [Received: 11/20/2023] [Revised: 12/15/2023] [Accepted: 12/29/2023] [Indexed: 01/12/2024]
Abstract
OBJECTIVE To describe clinical, functional, surgical, and outcomes data in pediatric patients with a myocardial bridge (MB) evaluated and managed following a standardized approach. METHODS Prospective observational study included patients evaluated in the Coronary Artery Anomalies Program. Anatomy was determined by computed tomography angiography, myocardial perfusion by stress perfusion imaging, and coronary hemodynamic assessment by cardiac catheterization. RESULTS In total, 39 of 42 patients with a complete evaluation for MB were included (December 2012 to June 2022) at a median age of 14.1 years (interquartile range, 12.2-16.4). Sudden cardiac arrest occurred in 3 of 39 (8%), exertional symptoms in 14 (36%), and no/nonspecific symptoms in 7 (18%) patients. Exercise stress test was abnormal in 3 of 34 (9%), stress perfusion imaging in 8 of 34 (24%), and resting instantaneous wave-free ratio ≤0.89 or diastolic dobutamine fractional flow reserve ≤0.80 in 11 of 21 (52%) patients. As a result, 15 of 39 (38%) patients were determined to have hemodynamically significant MB, 1 of 15 patients started beta-blocker, and 14 of 15 were referred for surgery. Myotomy (n = 11) and coronary bypass (n = 1) were performed successfully, resulting in improved symptoms and stress testing results. One patient required pericardiocentesis postoperatively, and all were discharged without other complications. At median follow-up time of 2.9 (1.8-5.8) years, all (except 2 pending surgery) were doing well without exercise restriction. CONCLUSIONS Pediatric patients with MB can present with myocardial ischemia and sudden cardiac arrest. Provocative stress test and intracoronary hemodynamic tests helped risk-stratify symptomatic patients with MB and concern for ischemia. Surgical repair was safe and effective in mitigating exertional symptoms and stress test results, allowing patients to return to exercise without restriction.
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Affiliation(s)
- Tam T Doan
- Coronary Artery Anomalies Program, Texas Children's Heart Center, Houston, Tex; Division of Cardiology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Tex.
| | - Carlos Bonilla-Ramirez
- General Surgery Residency Program, Department of Surgery, McGovern Medical School at UTHealth Houston, Houston, Tex
| | - Lindsay Eilers
- Coronary Artery Anomalies Program, Texas Children's Heart Center, Houston, Tex; Division of Cardiology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Tex
| | - Dana Reaves-O'Neal
- Coronary Artery Anomalies Program, Texas Children's Heart Center, Houston, Tex; Division of Cardiology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Tex
| | - Shagun Sachdeva
- Coronary Artery Anomalies Program, Texas Children's Heart Center, Houston, Tex; Division of Cardiology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Tex
| | - Stephen J Dolgner
- Coronary Artery Anomalies Program, Texas Children's Heart Center, Houston, Tex; Division of Cardiology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Tex
| | - Prakash M Masand
- Coronary Artery Anomalies Program, Texas Children's Heart Center, Houston, Tex; Division of Pediatric Radiology, Department of Radiology, Texas Children's Hospital, Baylor College of Medicine, Houston, Tex
| | - Srinath Gowda
- Coronary Artery Anomalies Program, Texas Children's Heart Center, Houston, Tex; Division of Cardiology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Tex
| | - Athar M Qureshi
- Coronary Artery Anomalies Program, Texas Children's Heart Center, Houston, Tex; Division of Cardiology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Tex
| | - Ziyad Binsalamah
- Coronary Artery Anomalies Program, Texas Children's Heart Center, Houston, Tex; Division of Congenital Heart Surgery, Department of Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Tex
| | - Silvana Molossi
- Coronary Artery Anomalies Program, Texas Children's Heart Center, Houston, Tex; Division of Cardiology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Tex.
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6
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Molossi S, Doan T, Sachdeva S. Anomalous Coronary Arteries: A State-of-the-Art Approach. Interv Cardiol Clin 2024; 13:51-70. [PMID: 37980067 DOI: 10.1016/j.iccl.2023.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2023]
Abstract
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.
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Affiliation(s)
- Silvana Molossi
- Coronary Artery Anomalies Program, Texas Children's Hospital, 6651 Main Street, MC E1920, Houston, TX 77030, USA; The Lillie Frank Abercrombie Section of Cardiology, Texas Children's Hospital, Baylor College of Medicine, 6651 Main Street, MC E1920, Houston, TX 77030, USA.
| | - Tam Doan
- Coronary Artery Anomalies Program, Texas Children's Hospital, 6651 Main Street, MC E1920, Houston, TX 77030, USA; The Lillie Frank Abercrombie Section of Cardiology, Texas Children's Hospital, Baylor College of Medicine, 6651 Main Street, MC E1920, Houston, TX 77030, USA
| | - Shagun Sachdeva
- Coronary Artery Anomalies Program, Texas Children's Hospital, 6651 Main Street, MC E1920, Houston, TX 77030, USA; The Lillie Frank Abercrombie Section of Cardiology, Texas Children's Hospital, Baylor College of Medicine, 6651 Main Street, MC E1920, Houston, TX 77030, USA
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7
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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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8
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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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9
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Angelini P, Uribe C, Corno AF. Pathophysiology and Treatment of Intraseptal-Course Left Coronary Anomaly: Surgery for All? Pediatr Cardiol 2023:10.1007/s00246-023-03328-1. [PMID: 37943349 DOI: 10.1007/s00246-023-03328-1] [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] [Received: 03/24/2023] [Accepted: 10/16/2023] [Indexed: 11/10/2023]
Abstract
Intraseptal-course, ectopic coronary anomalies are not well characterized as to anatomy, function, prognosis, and treatment. Recently, a revolutionary but unsupported new theory is claiming that most patients with a Left Anomalous Coronary Artery originating from the Opposite Sinus with anomalous Intra-Septal course (L-ACAOS-IS)-even small children-have significant stenoses and require open-heart surgery to prevent acute myocardial infarction and death. This surprising view has spurred ongoing discussions among adult and pediatric cardiologists and cardiac surgeons, compelling us (the conservative party in the discussion) to offer an in-depth and comprehensive review of this anomaly, based on objective but opposite data. We and other adult cardiologists have followed numerous L-ACAOS-IS patients for many years and have observed none of the claimed catastrophes. Rather, we have consistently found that L-ACAOS-IS generally has a benign clinical prognosis. We present the general principle of coronary artery dysfunction in anatomical congenital anomalies (that only significant luminal coronary stenosis can have clinical repercussions). We then review anatomical and functional details of L-ACAOS-IS related to prognosis and treatment indications, which could explain many of the clinical presentations recently mentioned. Finally, we encourage our more liberal colleagues to recognize that, compared with normal coronary arteries, those with anomalies of origin and course are associated with frequent coronary spasm. In particular, we underscore that some of the ischemic manifestations and other results might actually be caused by pressure wire-induced artifacts (rigid wires tend to cause coronary spasm when advanced into tortuous coronary arteries).
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Affiliation(s)
- Paolo Angelini
- The Texas Heart Institute Center for Cardiovascular Care, Houston, TX, USA
| | - Carlo Uribe
- The Texas Heart Institute Center for Cardiovascular Care, Houston, TX, USA
| | - Antonio F Corno
- School of Engineering, University of Leicester, University Road, Leicester, LE1 7RH, UK.
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10
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Kalustian AB, Doan TT, Masand P, Gowda ST, Eilers LF, Reaves-O'Neal DL, Sachdeva S, Qureshi AM, Heinle J, Molossi SM, Binsalamah ZM. Evolution of surgical repair of intraseptal anomalous left coronary artery with myocardial ischaemia. Cardiol Young 2023; 33:2342-2349. [PMID: 36861393 DOI: 10.1017/s1047951123000197] [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] [Indexed: 03/03/2023]
Abstract
BACKGROUND Anomalous aortic origin of the left coronary artery with intraseptal course is a rare coronary anomaly associated with an increased risk of myocardial ischaemia. The role and techniques for surgical intervention are evolving, with numerous novel surgical techniques for this challenging anatomy reported in the last 5 years. We report our single-centre experience with surgical repair of intraseptal anomalous left coronary artery in the paediatric population, including clinical presentation, evaluation, and short- to mid-term outcomes. METHODS All patients with coronary anomalies presenting to our institution undergo standardised clinical evaluation. Five patients aged 4 to 17 years underwent surgical intervention for intraseptal anomalous aortic origin of the left coronary artery between 2012 and 2022. Surgical techniques included coronary artery bypass grafting (n = 1), direct reimplantation with limited supra-arterial myotomy via right ventriculotomy (n = 1), and transconal supra-arterial myotomy with right ventricular outflow tract patch reconstruction (n = 3). RESULTS All patients had evidence of haemodynamically significant coronary compression, and three had evidence of inducible myocardial ischaemia pre-operatively. There were no deaths or major complications. Median follow-up was 6.1 months (range 3.1-33.4 months). Patients who underwent supra-arterial myotomy (with or without reimplantation) had improved coronary flow and perfusion based on stress imaging and catheterisation data. CONCLUSIONS Surgical approaches to intraseptal anomalous left coronary artery with evidence of myocardial ischaemia continue to evolve, with new techniques demonstrating promising improvement in coronary perfusion. Further studies are warranted to determine long-term outcomes and refine indications for repair.
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Affiliation(s)
- Alyssa B Kalustian
- Division of Congenital Heart Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Tam T Doan
- Division of Pediatric Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Prakash Masand
- Division of Pediatric Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Srinath T Gowda
- Division of Pediatric Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Lindsay F Eilers
- Division of Pediatric Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Dana L Reaves-O'Neal
- Division of Pediatric Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Shagun Sachdeva
- Division of Pediatric Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Athar M Qureshi
- Division of Pediatric Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Jeffrey Heinle
- Division of Congenital Heart Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Silvana M Molossi
- Division of Pediatric Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Ziyad M Binsalamah
- Division of Congenital Heart Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
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11
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Zeppilli P, Bianco M, Gervasi SF, Cammarano M, Monti R, Sollazzo F, Modica G, Morra L, Nifosì FM, Palmieri V. Congenital coronary artery anomalies in sports medicine. Why to know them. Clin Cardiol 2023; 46:1038-1048. [PMID: 37432696 PMCID: PMC10540032 DOI: 10.1002/clc.24084] [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] [Received: 04/11/2023] [Revised: 06/15/2023] [Accepted: 06/27/2023] [Indexed: 07/12/2023] Open
Abstract
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.
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Affiliation(s)
- Paolo Zeppilli
- Sports Medicine Unit, Fondazione Policlinico Universitario A. Gemelli IRCCSCatholic UniversityRomeItaly
| | - Massimiliano Bianco
- Sports Medicine Unit, Fondazione Policlinico Universitario A. Gemelli IRCCSCatholic UniversityRomeItaly
| | - Salvatore F. Gervasi
- Sports Medicine Unit, Fondazione Policlinico Universitario A. Gemelli IRCCSCatholic UniversityRomeItaly
| | - Michela Cammarano
- Sports Medicine Unit, Fondazione Policlinico Universitario A. Gemelli IRCCSCatholic UniversityRomeItaly
| | - Riccardo Monti
- Sports Medicine Unit, Fondazione Policlinico Universitario A. Gemelli IRCCSCatholic UniversityRomeItaly
| | - Fabrizio Sollazzo
- Sports Medicine Unit, Fondazione Policlinico Universitario A. Gemelli IRCCSCatholic UniversityRomeItaly
| | - Gloria Modica
- Sports Medicine Unit, Fondazione Policlinico Universitario A. Gemelli IRCCSCatholic UniversityRomeItaly
| | - Lorenzo Morra
- Sports Medicine Unit, Fondazione Policlinico Universitario A. Gemelli IRCCSCatholic UniversityRomeItaly
| | - Francesco M. Nifosì
- Sports Medicine Unit, Fondazione Policlinico Universitario A. Gemelli IRCCSCatholic UniversityRomeItaly
| | - Vincenzo Palmieri
- Sports Medicine Unit, Fondazione Policlinico Universitario A. Gemelli IRCCSCatholic UniversityRomeItaly
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Doan TT, Wilkes JK, Reaves O'Neal DL, Bonilla-Ramirez C, Sachdeva S, Masand P, Mery CM, Binsalamah Z, Heinle JS, Molossi S. Clinical Presentation and Medium-Term Outcomes of Children With Anomalous Aortic Origin of the Left Coronary Artery: High-Risk Features Beyond Interarterial Course. Circ Cardiovasc Interv 2023; 16:e012635. [PMID: 37192311 DOI: 10.1161/circinterventions.122.012635] [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] [Received: 12/28/2022] [Accepted: 04/04/2023] [Indexed: 05/18/2023]
Abstract
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.
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Affiliation(s)
- Tam T Doan
- Division of Cardiology, Department of Pediatrics (T.T.D., D.L.R.O., S.S., S.M.), Texas Children's Hospital, Baylor College of Medicine, Houston
| | - J Kevin Wilkes
- Pediatric Cardiology, Cook Children's Medical Center, Fort Worth, TX (J.K.W.)
| | - Dana L Reaves O'Neal
- Division of Cardiology, Department of Pediatrics (T.T.D., D.L.R.O., S.S., S.M.), Texas Children's Hospital, Baylor College of Medicine, Houston
| | - Carlos Bonilla-Ramirez
- Congenital Heart Surgery, Department of Surgery (C.B.-R., Z.B., J.S.H.), Texas Children's Hospital, Baylor College of Medicine, Houston
| | - Shagun Sachdeva
- Division of Cardiology, Department of Pediatrics (T.T.D., D.L.R.O., S.S., S.M.), Texas Children's Hospital, Baylor College of Medicine, Houston
| | - Prakash Masand
- Pediatric Radiology (P.M.), Texas Children's Hospital, Baylor College of Medicine, Houston
| | - Carlos M Mery
- Texas Center for Pediatric and Congenital Heart Disease, University of Texas Dell Medical School/Dell Children's Medical Center, Austin (C.M.M.)
| | - Ziyad Binsalamah
- Congenital Heart Surgery, Department of Surgery (C.B.-R., Z.B., J.S.H.), Texas Children's Hospital, Baylor College of Medicine, Houston
| | - Jeffrey S Heinle
- Congenital Heart Surgery, Department of Surgery (C.B.-R., Z.B., J.S.H.), Texas Children's Hospital, Baylor College of Medicine, Houston
| | - Silvana Molossi
- Division of Cardiology, Department of Pediatrics (T.T.D., D.L.R.O., S.S., S.M.), Texas Children's Hospital, Baylor College of Medicine, Houston
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13
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Molossi S, Doan T, Sachdeva S. Anomalous Coronary Arteries. Cardiol Clin 2023; 41:51-69. [DOI: 10.1016/j.ccl.2022.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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14
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Surgical Pearls of the Transconal Unroofing Procedure-Modifications and Midterm Outcomes. Ann Thorac Surg 2023; 115:e29-e31. [PMID: 35490772 DOI: 10.1016/j.athoracsur.2022.04.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 03/29/2022] [Accepted: 04/10/2022] [Indexed: 12/31/2022]
Abstract
We have previously described our novel surgical technique in addressing the anomalous aortic origin of the left coronary artery with a transseptal course behind the right ventricular outflow tract. By means of the Najm procedure, we performed complete unroofing of the transseptal anomalous aortic origin of the left coronary artery and elongated the right ventricular outflow tract posteriorly using an autologous pericardial patch. This report documents modifications to address challenging anatomic variants and highlights the importance of managing septal arteries and myocardial bridges. We also describe the excellent midterm outcomes of 14 patients who have undergone the Najm procedure.
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15
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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: 18] [Impact Index Per Article: 9.0] [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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16
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Can we talk? The residual, urgent questions about surgery for coronary artery anomalies. JTCVS OPEN 2022; 11:127-128. [PMID: 36172437 PMCID: PMC9510787 DOI: 10.1016/j.xjon.2022.04.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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17
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Qasim A, Doan TT, Dan Pham T, Reaves-O'Neal D, Sachdeva S, Mery CM, Binsalamah Z, Molossi S. Is Exercise Stress Testing Useful for Risk Stratification in Anomalous Aortic Origin of a Coronary Artery? Semin Thorac Cardiovasc Surg 2022; 35:759-768. [PMID: 36041683 DOI: 10.1053/j.semtcvs.2022.08.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 08/22/2022] [Indexed: 11/11/2022]
Abstract
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.
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Affiliation(s)
- Amna Qasim
- The Lillie Frank Abercrombie Section of Cardiology, Texas Children's Hospital, Department of Pediatrics, Baylor College of Medicine, Houston, Texas; The Coronary Artery Anomalies Program, Texas Children's Hospital, Houston, Texas.
| | - Tam T Doan
- The Lillie Frank Abercrombie Section of Cardiology, Texas Children's Hospital, Department of Pediatrics, Baylor College of Medicine, Houston, Texas; The Coronary Artery Anomalies Program, Texas Children's Hospital, Houston, Texas.
| | - Tam Dan Pham
- The Lillie Frank Abercrombie Section of Cardiology, Texas Children's Hospital, Department of Pediatrics, Baylor College of Medicine, Houston, Texas.
| | - Dana Reaves-O'Neal
- The Lillie Frank Abercrombie Section of Cardiology, Texas Children's Hospital, Department of Pediatrics, Baylor College of Medicine, Houston, Texas; The Coronary Artery Anomalies Program, Texas Children's Hospital, Houston, Texas.
| | - Shagun Sachdeva
- The Lillie Frank Abercrombie Section of Cardiology, Texas Children's Hospital, Department of Pediatrics, Baylor College of Medicine, Houston, Texas; The Coronary Artery Anomalies Program, Texas Children's Hospital, Houston, Texas.
| | - Carlos M Mery
- Texas Center for Pediatric and Congenital Heart Disease, University of Texas Dell Medical School, Dell Children's Medical Center, The University of Texas at Austin, Austin, Texas.
| | - Ziyad Binsalamah
- The Coronary Artery Anomalies Program, Texas Children's Hospital, Houston, Texas; Division of Congenital Heart Surgery, Michael E. DeBakey Department of Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas.
| | - Silvana Molossi
- The Lillie Frank Abercrombie Section of Cardiology, Texas Children's Hospital, Department of Pediatrics, Baylor College of Medicine, Houston, Texas; The Coronary Artery Anomalies Program, Texas Children's Hospital, Houston, Texas.
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18
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Ponzoni M, Frigo AC, Padalino MA. Surgery for Anomalous Aortic Origin of a Coronary Artery (AAOCA) in Children and Adolescents: A Meta-Analysis. World J Pediatr Congenit Heart Surg 2022; 13:485-494. [PMID: 35757950 DOI: 10.1177/21501351221095424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We conducted a systematic review and meta-analysis of the literature to assess the outcomes of surgery for the anomalous aortic origin of a coronary artery in children and young adults (<30 years). Thirteen publications were selected, including a total of 384 patients. Unroofing of the intramural segment was adopted in 92% (95% CI: 81%-98%) of cases, with pooled early and late mortality of 0% (95% CI: 0%-0.3%) and 0.1% (95% CI: 0%-1%), respectively. Reoperation for aortic regurgitation was anecdotal. Surgical management of anomalous aortic origin of coronary arteries can be achieved with excellent results in pediatric patients, but concerns remain about the durability of surgery.
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Affiliation(s)
- Matteo Ponzoni
- Pediatric and Congenital Cardiac Surgery Unit, Padova, Veneto, Italy
| | - Anna C Frigo
- Unit of Biostatistics, Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, University of Padova Medical School, Italy
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Hu F, Wang X, Wan J, Li Y, Wang T, Zhou K, Shi X, Liu Z, Fang J, Hua Y. An Atypical Anomalous Aortic Origin of the Left Coronary Artery With Intra-Arterial Wall Course Pretending a Normal Migration on Imaging Screening: A Case Report. Front Cardiovasc Med 2022; 9:918832. [PMID: 35757337 PMCID: PMC9222707 DOI: 10.3389/fcvm.2022.918832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 05/26/2022] [Indexed: 11/13/2022] Open
Abstract
Background An anomalous aortic origin of a coronary artery (AAOCA) has been considered as a dominant cause of sudden cardiac death (SCD) among young age children. Therefore, it is critical to identify AAOCA timely to avoid lethal events. Recently, accumulating cases of right or left coronary arteries originating from inappropriate locations at the sinus of Valsalva have been identified. Here, we report a rare case of AAOCA with an intra-arterial wall course pretending normal migration on imaging screening in a patient who suffered from syncope. Case summary A 7-year-old male without a previous history of cardiovascular and cerebrovascular diseases suddenly suffered from sharp chest pain and syncope after intensive exercise. The electrocardiogram showed that the ST segment of multiple leads was depressed by more than 0.05 mV, and biomarkers indicated severe myocardial injuries. The left ventricular ejection fraction (LVEF) decreased dramatically to 23%. Fulminant myocarditis and cardiomyopathy were therefore excluded. However, a relatively normal coronary artery origin, which arose from the left coronary sinus, presented on echocardiography and cardiac CT angiography (CTA). It is difficult to draw an association between severe clinical manifestations and slight malformations on echocardiography and CTA. Furthermore, selective coronary angiography revealed that an anomalous left coronary artery arose from the superior margin of the inappropriate sinus, developed an intramural wall course and finally exits the left sinus of Valsalva and migrated between the aorta and the pulmonary artery, which induced severe myocardial infarction during exercise. Then, the patient received surgical correction with a modified unroofing procedure. After 2 months of intensive treatment, the patient was discharged and remained asymptomatic through 18 months of follow-up. Conclusion AAOCA, especially anomalous left coronary artery (ALCA), represents a major potential risk of SCD. We reported an atypical manifestation of ALCA arising from the inappropriate sinus of Valsalva and merging into the intra-arterial wall to develop a strange course and then sprout between the aorta and the pulmonary artery. The diversity of AAOCA might present as a relatively normal course under non-invasive radiological imaging scanning.
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20
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Jiang MX, Brinza EK, Ghobrial J, Tucker DL, Gupta S, Rajeswaran J, Karamlou T. Coronary artery disease in adults with anomalous aortic origin of a coronary artery. JTCVS OPEN 2022; 10:205-221. [PMID: 36004264 PMCID: PMC9390708 DOI: 10.1016/j.xjon.2022.04.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 03/01/2022] [Accepted: 04/12/2022] [Indexed: 12/01/2022]
Abstract
Objectives This study sought to characterize coronary artery disease (CAD) among adults diagnosed with an anomalous aortic origin of a coronary artery (AAOCA). We hypothesized that coronaries with anomalous origins have more severe CAD stenosis than coronaries with normal origins. Methods This single-center study of 763 adults with AAOCA consisted of 620 patients from our cardiac catheterization database (1958-2009) and 273 patients from electronic medical records query (2010-2021). Within left main, anterior descending, circumflex, and right coronary arteries, the CAD stenosis severity, assessed by invasive or computer tomography angiography, was modeled with coronary-level variables (presence of an anomalous origin) and patient-level variables (age, sex, comorbidities, and which of the four coronaries was anomalous). Results Of the 763 patients, 472 (60%) had obstructive CAD, of whom, 142/472 (30%) had obstructive CAD only in the anomalous coronary. Multivariable modeling showed similar CAD stenosis severity between coronaries with anomalous versus normal origins (P = .8). Compared with AAOCA of other coronaries, the anomalous circumflex was diagnosed at older ages (59.7 ± 11.1 vs 54.3 ± 15.8 years, P < .0001) and was associated with increased stenosis in all coronaries (odds ratio, 2.7; 95% confidence interval, 2.2-3.4, P < .0001). Conclusions Among adults diagnosed with AAOCA, the anomalous origin did not appear to increase the severity of CAD within the anomalous coronary. In contrast to the circumflex, AAOCA of the other vessels may contribute a greater ischemic burden when they present symptomatically at younger ages with less CAD. Future research should investigate the interaction between AAOCA, CAD, and ischemic risk to guide interventions.
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Affiliation(s)
- Michael X. Jiang
- Department of Pediatrics, Cleveland Clinic Children's Hospital, Cleveland, Ohio
| | - Ellen K. Brinza
- Cleveland Clinic Lerner College of Medicine at Case Western Reserve University, Cleveland, Ohio
| | - Joanna Ghobrial
- Department of Cardiovascular Medicine, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Dominique L. Tucker
- Case Western Reserve University School of Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Sohini Gupta
- Case Western Reserve University School of Medicine, Cleveland Clinic, Cleveland, Ohio
| | | | - Tara Karamlou
- Department of Thoracic and Cardiovascular Surgery, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
- Address for reprints: Tara Karamlou, MD, MSc, Division of Pediatric Cardiac Surgery and the Heart Vascular, and Thoracic Institute, 9500 Euclid Ave, M41-022A, Cleveland, OH 44195.
| | - Cleveland Clinic Adult AAOCA Working Group∗BlackstoneEugene H.MDefSaarelElizabeth V.MDghGuptaSohiniBAiHammoudMiza SalimMDfVaidyaKiran A.BSbHauptMichael J.BSbCockrumJoshua W.BSbMhannaChristianeDOaGhobrialJoannaMDjAhmadMunirMDfSchoenhagenPaulMDkPetterssonGösta B.MD, PhDfNajmHani K.MD, MScfStewartRobert D.MD, MPHflDepartment of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OhioDepartment of Thoracic and Cardiovascular Surgery, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OhioDepartment of Pediatric Cardiology, Cleveland Clinic, Cleveland, OhioDepartment of Pediatric Cardiology, St. Luke's Children's Hospital, Boise, IdahoCase Western Reserve University School of Medicine, Cleveland, OhioCleveland Clinic Lerner College of Medicine at Case Western Reserve University, Cleveland, OhioDepartment of Pediatrics, Cleveland Clinic Children's Hospital, Cleveland, OhioDepartment of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OhioDepartment of Cardiovascular Imaging, Cleveland Clinic, Cleveland, OhioDepartment of Cardiovascular Surgery, Akron Children's Hospital, Akron, Ohio
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Williams SB, Dan N Pham T, Doan TT, Reaves-O’Neal D, Bonilla-Ramirez C, Binsalamah ZM, Mery CM, Caldarone CA, Molossi S. Pattern, behavior and clinical implications of electrocardiographic changes in patients undergoing repair of anomalous aortic origin of coronary arteries. J Thorac Cardiovasc Surg 2022; 164:742-749. [DOI: 10.1016/j.jtcvs.2022.01.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 11/23/2021] [Accepted: 01/11/2022] [Indexed: 11/26/2022]
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22
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Carles G, Peyre M, Dabadie A, Macé L, Lenoir M. Ventricular septal defect with anomalous origin of the left descending coronary artery from the right sinus of Valsava and an intraseptal course. Asian Cardiovasc Thorac Ann 2021; 30:722-725. [PMID: 34605269 DOI: 10.1177/02184923211047054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Patients with anomalous aortic origin of the left anterior descending coronary artery (AAOCA) from the right sinus of Valsava, and associated with a trans-septal course, are recommended for surgery only when symptoms of ischemia are present. The transconal unroofing method is straightforward and provides good anatomic result. In absence of significant coronary compression, surgical management of the trans-septal coronary course is proposed if the patient is a candidate to cardiac surgery for another reason, such as congenital heart disease. We describe a transconal approach in a patient with a trans-septal coronary artery and a ventricular septal defect.
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Affiliation(s)
- Guillaume Carles
- Department of Pediatric Cardiology, Hôpital Timone enfant, AP-HM, Aix Marseille Univ, Marseille, France
| | - Marianne Peyre
- Department of Pediatric Cardiology, Hôpital Timone enfant, AP-HM, Aix Marseille Univ, Marseille, France
| | - Alexia Dabadie
- Department of Pediatric Radiology, Hôpital Timone enfant, AP-HM, Aix Marseille Univ, Marseille, France
| | - Loïc Macé
- Department of Pediatric Cardiac Surgery, Hôpital Timone enfant, AP-HM, Aix Marseille Univ, Marseille, France
| | - Marien Lenoir
- Department of Pediatric Cardiac Surgery, Hôpital Timone enfant, AP-HM, Aix Marseille Univ, Marseille, France
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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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Affiliation(s)
- Stephen Dolgner
- Adult Congenital Heart Program, Pediatrics, Section of Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA .,Coronary Anomalies Program, Pediatrics, Section of Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Edward Hickey
- Adult Congenital Heart Program, Department of Surgery, Division of Congenital Heart Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Silvana Molossi
- Coronary Anomalies Program, Pediatrics, Section of Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
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Jegatheeswaran A, Alsoufi B. Anomalous aortic origin of a coronary artery: 2020 year in review. J Thorac Cardiovasc Surg 2021; 162:353-359. [PMID: 34120742 DOI: 10.1016/j.jtcvs.2021.04.048] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 04/12/2021] [Accepted: 04/15/2021] [Indexed: 11/16/2022]
Affiliation(s)
- Anusha Jegatheeswaran
- Division of Cardiovascular Surgery, Department of Surgery, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.
| | - Bahaaldin Alsoufi
- Department of Cardiovascular and Thoracic Surgery, Norton Children's Hospital, University of Louisville School of Medicine, Louisville, Ky
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Rahmouni K, Bernier PL. Current Management of Anomalous Aortic Origin of a Coronary Artery: A Pan-Canadian Survey. World J Pediatr Congenit Heart Surg 2021; 12:387-393. [PMID: 33942683 PMCID: PMC8111229 DOI: 10.1177/2150135121999030] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
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.
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Affiliation(s)
- Kenza Rahmouni
- Department of Cardiac Surgery, 27339University of Ottawa Heart Institute, University of Ottawa, Ontario, Canada
| | - Pierre-Luc Bernier
- Faculty of Medicine, 5620McGill University, Montreal, Canada.,Division of Cardiac Surgery, Montreal Children's Hospital, McGill University Health Center, Montreal, Canada
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Catheter Selection and Angiographic Views for Anomalous Coronary Arteries: A Practical Guide. JACC Cardiovasc Interv 2021; 14:995-1008. [PMID: 33958174 DOI: 10.1016/j.jcin.2021.01.054] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 12/28/2020] [Accepted: 01/19/2021] [Indexed: 11/24/2022]
Abstract
Although congenital coronary artery anomalies are relatively rare, they are the second most common cause of sudden cardiac death among young athletes. When encountered in the cardiac catherization laboratory, they are often challenging to selectively engage, requiring multiple catheters, plus increased contrast volume and radiation exposure. In the setting of acute coronary syndromes, it is not infrequent that percutaneous intervention is delayed because of the inability to engage an anomalous coronary artery. The aim of this review is to provide a comprehensive and concise overview of coronary artery anomalies, with particular attention to diagnostic and guide catheter selection for each type of anomaly and recommendations on how to recognize the vessel course angiographically.
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Doan TT, Molossi S, Sachdeva S, Wilkinson JC, Loar RW, Weigand JD, Schlingmann TR, Reaves-O'Neal DL, Pednekar AS, Masand P, Noel CV. Dobutamine stress cardiac MRI is safe and feasible in pediatric patients with anomalous aortic origin of a coronary artery (AAOCA). Int J Cardiol 2021; 334:42-48. [PMID: 33892043 DOI: 10.1016/j.ijcard.2021.04.031] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 04/09/2021] [Accepted: 04/16/2021] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Tam T Doan
- Coronary Artery Anomalies Program, Texas Children's Hospital, 6651 Main Street, MC E1920, Houston, TX 77030, USA; The Lillie Frank Abercrombie Section of Cardiology, Texas Children's Hospital, Baylor College of Medicine, 6651 Main Street, MC E1920, Houston, TX 77030, USA.
| | - Silvana Molossi
- Coronary Artery Anomalies Program, Texas Children's Hospital, 6651 Main Street, MC E1920, Houston, TX 77030, USA; The Lillie Frank Abercrombie Section of Cardiology, Texas Children's Hospital, Baylor College of Medicine, 6651 Main Street, MC E1920, Houston, TX 77030, USA.
| | - Shagun Sachdeva
- Coronary Artery Anomalies Program, Texas Children's Hospital, 6651 Main Street, MC E1920, Houston, TX 77030, USA; The Lillie Frank Abercrombie Section of Cardiology, Texas Children's Hospital, Baylor College of Medicine, 6651 Main Street, MC E1920, Houston, TX 77030, USA
| | - James C Wilkinson
- The Lillie Frank Abercrombie Section of Cardiology, Texas Children's Hospital, Baylor College of Medicine, 6651 Main Street, MC E1920, Houston, TX 77030, USA
| | - Robert W Loar
- Pediatric Cardiology, Cook Children's Medical Center, 1500 Cooper St, Fort Worth, TX 76104, USA
| | - Justin D Weigand
- The Lillie Frank Abercrombie Section of Cardiology, Texas Children's Hospital, Baylor College of Medicine, 6651 Main Street, MC E1920, Houston, TX 77030, USA
| | - Tobias R Schlingmann
- The Lillie Frank Abercrombie Section of Cardiology, Texas Children's Hospital, Baylor College of Medicine, 6651 Main Street, MC E1920, Houston, TX 77030, USA
| | - Dana L Reaves-O'Neal
- Coronary Artery Anomalies Program, Texas Children's Hospital, 6651 Main Street, MC E1920, Houston, TX 77030, USA; The Lillie Frank Abercrombie Section of Cardiology, Texas Children's Hospital, Baylor College of Medicine, 6651 Main Street, MC E1920, Houston, TX 77030, USA
| | - Amol S Pednekar
- Department of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH 45229, USA
| | - Prakash Masand
- Coronary Artery Anomalies Program, Texas Children's Hospital, 6651 Main Street, MC E1920, Houston, TX 77030, USA; EB Singleton Department of Pediatric Radiology, Texas Children's Hospital, Baylor College of Medicine, 6651 Main Street, MC E1920, Houston, TX 77030, USA
| | - Cory V Noel
- Pediatric Cardiology of Alaska, Seattle Children's Hospital, 3841 Piper St, Suite T345, Anchorage, AK 99508, USA
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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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30
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Bonilla-Ramirez C, Molossi S, Caldarone CA, Binsalamah ZM. Anomalous Aortic Origin of the Coronary Arteries - State of the Art Management and Surgical Techniques. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2021; 24:85-94. [PMID: 34116787 DOI: 10.1053/j.pcsu.2021.03.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 02/17/2021] [Accepted: 03/07/2021] [Indexed: 11/11/2022]
Abstract
Anomalous aortic origin of a coronary artery (AAOCA) can be associated with myocardial ischemia and sudden cardiac arrest. We describe and compare the management and surgical techniques for patients with AAOCA. Patients presenting to the Coronary Artery Anomalies Program are evaluated and managed following a standardized approach. Our approach and data were compared to other single-center and multi-institutional data and results. Patients with AAOCA present as an incidental finding approximately 50% of the time. Advanced axial imaging is essential to define the anatomic characteristics of this lesion. Preoperative and postoperative assessment of myocardial perfusion with provocative testing is feasible and contributes to risk stratification. The surgical techniques for AAOCA repair include coronary unroofing, transection and reimplantation, and neo-ostium creation, among others. In general, surgical repair of AAOCA can mitigate the risk of ischemia with low mortality. The specific morbidities and complications of each different technique should be considered during the surgical planning. Surgical repair of AAOCA can mitigate the risk of ischemia with a low associated mortality but with clinically relevant morbidities. Long-term follow-up is necessary to accurately balance the risks of repaired and unrepaired AAOCA.
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Affiliation(s)
- Carlos Bonilla-Ramirez
- Coronary Artery Anomalies Program, Texas Children's Hospital; Houston, Texas; Division of Congenital Heart Surgery, Michael E. DeBakey Department of Surgery, Texas Children's Hospital, Baylor College of Medicine; Houston, Texas
| | - Silvana Molossi
- Coronary Artery Anomalies Program, Texas Children's Hospital; Houston, Texas; The Lillie Frank Abercrombie Section of Cardiology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine; Houston, Texas
| | - Christopher A Caldarone
- Coronary Artery Anomalies Program, Texas Children's Hospital; Houston, Texas; Division of Congenital Heart Surgery, Michael E. DeBakey Department of Surgery, Texas Children's Hospital, Baylor College of Medicine; Houston, Texas
| | - Ziyad M Binsalamah
- Coronary Artery Anomalies Program, Texas Children's Hospital; Houston, Texas; Division of Congenital Heart Surgery, Michael E. DeBakey Department of Surgery, Texas Children's Hospital, Baylor College of Medicine; Houston, Texas.
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31
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Han PL, Diao KY, Huang S, Gao Y, Guo YK, Yang ZG, Yang N. Anatomical characteristics of anomalous left coronary artery from the opposite sinus (left-ACAOS) and its clinical relevance: A serial coronary CT angiography study. IJC HEART & VASCULATURE 2020; 31:100649. [PMID: 33088901 PMCID: PMC7558218 DOI: 10.1016/j.ijcha.2020.100649] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Revised: 08/13/2020] [Accepted: 09/24/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND Anomalous left coronary artery from the opposite sinus (left-ACAOS) is a rare congenital heart disease. While "interarterial course" is considered as the malignant anatomic feature for these patients, a number of patients with left-ACAOS, who don't follow the above anatomic pattern, were reported with ischemic symptoms. PURPOSE This study aims to evaluate the anatomic characteristics of left-ACAOS and their clinical relevance. METHODS The coronary computed tomography angiography (CCTA) data from 44 patients with 46 left-ACAOS vessels were retrospectively included. Patients were divided into 2 groups: those with ischemic symptoms (n = 19) and those without ischemic symptoms (n = 25). Baseline clinical characteristics were recorded and the follow-up was done by telephone. CCTA images were reviewed for anomalous coronary artery, take-off angle and level, ostia morphology and grading, proximal narrowing, anomalous course and atherosclerotic plaques. RESULTS The prevalence of left-ACAOS was approximately 0.09% among 48, 719 consecutive patients referred for coronary CTA in our institution. Right sinus of Valsalva (RSV) was the most common origin (36/46, 78.26%). Left-ACAOS arising from right coronary artery (RCA) had narrower proximal segment (P = 0.014) and more prone to atherosclerosis (P = 0.040) than left-ACAOS arising from right sinus of Valsalva (RSV). Proximal narrowing severity (P < 0.001) and degree of maximal coronary stenosis (P = 0.034) of the anomalous left artery was higher in patients with ischemic symptoms than those without. Of note, no MACE was recorded during a mean follow-up of 43.4 ± 26.2 months. CONCLUSION Left-ACAOS arising from RCA seems to be more prone to atherosclerosis than other subtypes. Proximal narrowing was more severe in patients with ischemia symptoms, which may contribute to risk stratification and clinical management.
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Affiliation(s)
- Pei-lun Han
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, China
| | - Kai-yue Diao
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, China
| | - Shan Huang
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, China
| | - Yue Gao
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, China
| | - Ying-kun Guo
- Department of Radiology, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Zhi-gang Yang
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, China
| | - Ning Yang
- Cardiothoracic Surgery Department, Guang'an People's Hospital, Sichuan Province, China
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32
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Hatoum H, Krishnamurthy R, Parthasarathy J, Flemister DC, Krull CM, Walter BA, Mery CM, Molossi S, Dasi LP. Flow Dynamics in Anomalous Aortic Origin of a Coronary Artery in Children: Importance of the Intramural Segment. Semin Thorac Cardiovasc Surg 2020; 34:226-235. [PMID: 33242612 PMCID: PMC11062399 DOI: 10.1053/j.semtcvs.2020.11.027] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Accepted: 11/17/2020] [Indexed: 01/02/2023]
Abstract
This study aims to assess the differences in pressure, fractional flow reserve (FFR) and coronary flow (with increasing pressure) of the proximal coronary artery in patients with anomalous aortic origin of a coronary artery with a confirmed ischemic event, without ischemic events, and before and after unroofing surgery, and compare to a patient with normal coronary arteries. Patient-specific flow models were 3D printed for 3 subjects with anomalous right coronary arteries with intramural course, 2 of them had documented ischemia, and compared with a patient with normal coronaries. The models were placed in the aortic position of a pulse duplicator and precise measurements to quantify FFR and coronary flow rate were performed from the aortic to the mediastinal segment of the anomalous right coronary artery. In an ischemic model, a gradual FFR drop (emulating that of pressure) was shown from the ostium location (∼1.0) to the distal intramural course (0.48). In nonischemic and normal patient models, FFR for all locations did not drop below 0.9. In a second ischemic model prior to repair, a drop to 0.44 was encountered at the intramural and mediastinal intersection, improving to 0.86 postrepair. There is a difference in instantaneous coronary flow rate with increasing aortic pressure in the ischemic models (slope 0.2846), compared to the postrepair and normal models (slope >0.53). These observations on patient models support a biomechanical basis for ischemia and potentially sudden cardiac death in aortic origin of a coronary artery, with a drop in pressure and FFR in the intramural segment, and a decrease in coronary flow rate with increasing aortic pressure, with both improving after corrective surgery.
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Affiliation(s)
- Hoda Hatoum
- Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, Georgia
| | - Rajesh Krishnamurthy
- Department of Radiology, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio..
| | - Jayanthi Parthasarathy
- Department of Radiology, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio
| | - Dorma C Flemister
- Department of Biomedical Engineering, The Ohio State University, Columbus, Ohio
| | - Carly M Krull
- Department of Biomedical Engineering, The Ohio State University, Columbus, Ohio
| | - Benjamin A Walter
- Department of Biomedical Engineering, The Ohio State University, Columbus, Ohio
| | - Carlos M Mery
- Texas Center for Pediatric and Congenital Heart Disease, University of Texas Dell Medical School / Dell Children's Medical Center, Austin, Texas
| | - Silvana Molossi
- Section of Pediatric Cardiology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Lakshmi Prasad Dasi
- Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, Georgia..
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Intraseptal Anomalous Coronary Artery With Myocardial Infarction: Novel Surgical Approach. Ann Thorac Surg 2020; 110:e271-e274. [DOI: 10.1016/j.athoracsur.2020.02.076] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 02/26/2020] [Accepted: 02/28/2020] [Indexed: 11/23/2022]
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Well A, Mery CM. Intraseptal Anomalous Coronaries: A Radical Solution for a Radical Problem? Ann Thorac Surg 2020; 112:602. [PMID: 32603704 DOI: 10.1016/j.athoracsur.2020.05.054] [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: 05/03/2020] [Accepted: 05/06/2020] [Indexed: 11/20/2022]
Affiliation(s)
- Andrew Well
- Coronary Anomalies Program, Texas Center for Pediatric and Congenital Heart Disease, UT Health Austin/Dell Children's Medical Center, Austin, Texas; Department of Surgery and Perioperative Care, University of Texas at Austin/Dell Medical School, 4900 Mueller Blvd, Ste 3S.003, Austin, TX 78703
| | - Carlos M Mery
- Coronary Anomalies Program, Texas Center for Pediatric and Congenital Heart Disease, UT Health Austin/Dell Children's Medical Center, Austin, Texas; Department of Surgery and Perioperative Care, University of Texas at Austin/Dell Medical School, 4900 Mueller Blvd, Ste 3S.003, Austin, TX 78703.
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