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Stephens EH, Jegatheeswaran A, Brothers JA, Ghobrial J, Karamlou T, Francois CJ, Krishnamurthy R, Dearani JA, Binsalamah Z, Molossi S, Mery CM. Anomalous Aortic Origin of a Coronary Artery. Ann Thorac Surg 2024; 117:1074-1086. [PMID: 38302054 DOI: 10.1016/j.athoracsur.2024.01.016] [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] [Received: 10/01/2023] [Revised: 12/09/2023] [Accepted: 01/03/2024] [Indexed: 02/03/2024]
Abstract
BACKGROUND Although anomalous aortic origin of a coronary artery (AAOCA) is associated with risk of sudden cardiac arrest (SCA), there is a spectrum of disease, with the appropriate management for many remaining unclear. Increasing data warrant review for an updated perspective on management. METHODS A panel of congenital cardiac surgeons, cardiologists, and imaging practitioners reviewed the current literature related to AAOCA and its management. Survey of relevant publications from 2010 to the present in PubMed was performed. RESULTS The prevalence of AAOCA is 0.4% to 0.8%. Anomalous left coronary artery is 3 to 8 times less common than anomalous right coronary, but carries a much higher risk of SCA. Nevertheless, anomalous right coronary is not completely benign; 10% demonstrate ischemia, and it remains an important cause of SCA. Decision-making regarding which patients should be recommended for surgical intervention includes determining anatomic features associated with ischemia, evidence of ischemia on provocative testing, and concerning cardiovascular symptoms. Ischemia testing continues to prove challenging with low sensitivity and specificity, but the utility of new modalities is an active area of research. Surgical interventions focus on creating an unobstructed path for blood flow and choosing the appropriate surgical technique given the anatomy to accomplish this. Nontrivial morbidity has been reported with surgery, including new-onset ischemia. CONCLUSIONS A proportion of patients with AAOCA demonstrate features and ischemia that warrant surgical intervention. Continued work remains to improve the ability to detect inducible ischemia, to risk stratify these patients, and to provide guidance in terms of which patients warrant surgical intervention.
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Affiliation(s)
| | - Anusha Jegatheeswaran
- Department of Cardiothoracic Surgery, Great Ormond Street Hospital, London, United Kingdom; Department of Children's Cardiovascular Disease, Institute of Cardiovascular Science, University College London, London, United Kingdom
| | - Julie A Brothers
- Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - Tara Karamlou
- Division of Pediatric and Congenital Cardiac Surgery, Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | | | - Rajesh Krishnamurthy
- Division of Cardiovascular Imaging, Department of Radiology, Nationwide Children's Hospital, Columbus, Ohio
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Ziyad Binsalamah
- Division of Congenital Heart Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas
| | - Silvana Molossi
- Division of Cardiology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Carlos M Mery
- Department of Surgery and Perioperative Care, Dell Medical School at The University of Texas at Austin, Dell Children's Medical Center, Austin, Texas
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Fernandez-Cisneros A, Feins E, Newburger J, Sekhavat S, Quinn B, Quinonez L. Repeat Repair After Translocation of an Anomalous Left Coronary Artery. Ann Thorac Surg 2024:S0003-4975(24)00282-0. [PMID: 38621655 DOI: 10.1016/j.athoracsur.2024.03.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Accepted: 03/19/2024] [Indexed: 04/17/2024]
Abstract
We repaired a left anomalous aortic origin of coronary artery using coronary ostium translocation/reimplantation. Repeat repair was required due to suboptimal flow pattern in postoperative transesophageal echocardiography, which was confirmed with coronary angiography. We emphasize the importance of early recognition, diagnosis, and intervention to deal with a problem with the coronary repair.
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Affiliation(s)
| | - Eric Feins
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jane Newburger
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sepehr Sekhavat
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Brian Quinn
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Luis Quinonez
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts.
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Burns J, Emeruwa E, Connell P, Borges N, Reaves-O'Neal D, Molossi S. High-Risk Anomalous Aortic Origin of the Left Coronary Artery: Consecutive Admissions Presenting With Sudden Cardiac Arrest. World J Pediatr Congenit Heart Surg 2024; 15:349-352. [PMID: 38632690 DOI: 10.1177/21501351241237945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
Anomalous aortic origin of the left coronary artery (AAOLCA) confers high risk for sudden cardiac arrest (SCA). This series aims to describe consecutive admissions with interarterial AAOLCA presenting with SCA and distinct clinical trajectories. An eight-year-old boy collapsed at school and received 10-min of cardiopulmonary resuscitation (CPR) and defibrillation prior to return of spontaneous circulation. He had no end-organ dysfunction and underwent uneventful coronary unroofing. In contrast, a 14-year-old boy presented with collapse while jogging. He received 40-min of CPR prior to extracorporeal membranous oxygenation cannulation with multisystem dysfunction and persistent severely depressed left ventricular function. He is now rehabilitating following uneventful orthotropic heart transplantation. These cases illustrate the diverse outcomes of AAOLCA with SCA following exertional syncope.
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Affiliation(s)
- Joseph Burns
- Division of Cardiology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Ezinne Emeruwa
- Division of Critical Care Medicine, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Patrick Connell
- Division of Pediatric Cardiology, University of Michigan, Ann Arbor, MI, USA
| | - Nirica Borges
- Division of Critical Care Medicine, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Dana Reaves-O'Neal
- Division of Cardiology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Silvana Molossi
- Division of Cardiology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
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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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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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Kohlsaat K, Gauvreau K, Beroukhim R, Newburger JW, Quinonez L, Nathan M. Trends in surgical management of anomalous aortic origin of the coronary artery over 2 decades. JTCVS OPEN 2023; 16:757-770. [PMID: 38204671 PMCID: PMC10774946 DOI: 10.1016/j.xjon.2023.07.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 07/16/2023] [Accepted: 07/19/2023] [Indexed: 01/12/2024]
Abstract
Objective To evaluate outcomes of patients undergoing surgery for anomalous aortic origin of the coronary artery (AAOCA) at a tertiary care center and determine the influences of a coronary artery program on management strategies and outcomes. Methods This retrospective review of consecutive surgical patients who had isolated AAOCA at a tertiary care center between August 1, 1999, and October 31, 2022, compared patient characteristics, interventional timing, and surgical strategies before and after program inception in 2018. Comparisons between time periods and anatomical subgroups were performed using Fisher exact and Wilcoxon rank-sum tests. Results Of 149 surgical AAOCA patients, 102 (69%) had AAO of the right coronary artery. Compared with AAO of the left coronary artery (AAOLCA), AAO of the right coronary artery (AAORCA) was associated with greater athletic participation (intramural, varsity, and college-level) (74% vs 43%; P < .001) and preoperative functional imaging (72% vs 49%; P = .01), but were less likely to have ischemic changes on functional imaging (5% vs 23%; P = .03) or any postoperative complications (7% vs 19%; P = .04). Moderate or greater aortic insufficiency occurred postoperatively in 1 (1%) of AAORCA and 1 (3%) of AAOLCA patients. After the coronary artery program inception, there was an increase among patients with AAOCA undergoing preoperative computed tomography angiography (pre-2018: 39 out of 98 [40%] vs post-2018: 48 out of 51 [94%]; P < .001) and a decrease in isolated AAOCA unroofing procedures performed (30 [31%] vs 5 [10%]; P = .004). Conclusions Surgical management of AAOCA evolved over time, and can be achieved with low instance of postoperative aortic insufficiency. Establishment of a coronary artery program has streamlined care.
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Affiliation(s)
| | - Kimberlee Gauvreau
- Department of Cardiology, Boston Children's Hospital, Boston, Mass
- Department of Biostatistics, Harvard School of Public Health, Boston, Mass
| | - Rebecca Beroukhim
- Department of Cardiology, Boston Children's Hospital, Boston, Mass
- Department of Pediatrics, Harvard Medical School, Boston, Mass
| | - Jane W. Newburger
- Department of Cardiology, Boston Children's Hospital, Boston, Mass
- Department of Pediatrics, Harvard Medical School, Boston, Mass
| | - Luis Quinonez
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass
- Department of Surgery, Harvard Medical School, Boston, Mass
| | - Meena Nathan
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass
- Department of Surgery, Harvard Medical School, Boston, Mass
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Doan TT, Sachdeva S, Bonilla-Ramirez C, Reaves-O'Neal D, Masand P, Krishnamurthy R, Jadhav S, Mery CM, Binsalamah Z, Molossi S. Anomalous Aortic Origin of Coronary Arteries in Children: Postoperative High-risk Anatomic Features. Ann Thorac Surg 2023; 115:991-998. [PMID: 36470562 DOI: 10.1016/j.athoracsur.2022.11.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 11/09/2022] [Accepted: 11/14/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND This study aimed to assess postoperative presumed high-risk anatomic features (HRAFs) by using computed tomographic angiography (CTA) in patients with anomalous aortic origin of a coronary artery (AAOCA) after surgical unroofing vs transection and reimplantation (TAR) if unroofing was thought to provide unsatisfactory results. METHODS The study included 62 children with postoperative CTA performed at a median of 3 months (interquartile range, 3-4 months) after unroofing (n = 45) and TAR (n = 17). HRAFs included slitlike ostium, intramural course, acute angle takeoff (<45o), interarterial course, proximal stenosis >50%, or course through a thickened intercoronary pillar. RESULTS Median age at surgery was 13.8 years (interquartile range, 10.5-15.8 years). None of the patients had a slitlike ostium or an intramural course on postoperative CTA. Acute takeoff was seen in 100% after unroofing and in 2 of 17 (12%) after TAR (P < .001). After unroofing, the interarterial course improved to 35 of 45 (78%) from 43 of 45 (96%) (P = .003), and a thickened intercoronary pillar improved to 10 of 45 (22%) from 22 of 45 (49%) (P = .0001), compared with none seen after TAR. Preoperative intramural length <5 mm was associated with a postoperative thickened intercoronary pillar in right AAOCA after unroofing (P = .0004). Severe coronary stenosis occurred in 2 of 17 (12%) after TAR, and both patients needed urgent revision procedures. All patients except 2 (97%) returned to exercise activities at a median follow-up of 4.9 years (range, 0.6-9.2 years). CONCLUSIONS The slitlike ostium and intramural course resolved in all patients. Residual acute angle takeoff, an interarterial course, and mild coronary narrowing related to a thickened intercoronary pillar were common after unroofing. TAR allows resolution of all HRAFs, although severe narrowing requiring surgical revision happened only in TAR. Long-term studies are needed to understand the clinical significance of these residual presumed HRAFs.
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Affiliation(s)
- Tam T Doan
- Coronary Artery Anomalies Program, Section of Cardiology, Texas Children's Hospital, Houston, Texas.
| | - Shagun Sachdeva
- Coronary Artery Anomalies Program, Section of Cardiology, Texas Children's Hospital, Houston, Texas
| | - Carlos Bonilla-Ramirez
- Department of Congenital Heart Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Dana Reaves-O'Neal
- Coronary Artery Anomalies Program, Section of Cardiology, Texas Children's Hospital, Houston, Texas
| | - Prakash Masand
- Department of Pediatric Radiology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | | | - Siddharth Jadhav
- Department of Pediatric Radiology, Texas Children's Hospital, Baylor College of Medicine, 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
- Department of Congenital Heart Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Silvana Molossi
- Coronary Artery Anomalies Program, Section of Cardiology, Texas Children's Hospital, Houston, Texas
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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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