Anomalous coronary arteries: what is known and what still remains to be learned?

Wall motion assessment by feature tracking in pediatric patients with coronary anomalies undergoing dobutamine stress CMR

Background

Left ventricular (LV) wall motion assessment is an important adjunct in addition to perfusion defects in assessing ischemic changes. This study aims to investigate the feasibility and utility of performing feature tracking (FT) in pediatric patients with coronary anomalies undergoing dobutamine stress CMR to assess wall motion abnormalities (WMA) and perfusion defects.

Method

This is a retrospective study where 10 patients with an inducible first-pass perfusion (FPP) defect and 10 without were selected. Global LV circumferential strain/strain rate (GCS/GCSR) was measured at rest and at peak stress (systole and diastole) using a commercially available feature tracking software. Peak GCS and GCSR were compared to indexed wall motion score (WMSI) between groups with and without FPP defect and in subjects with and without WMA.

Results

The median age of patients was 13.5 years (Q1, 11 years; Q3, 15 years). Five subjects had qualitatively WMA at peak stress. A moderate correlation of GCS with WMSI at peak stress (0.48, p = 0.026) and a significant difference between GCS at rest and stress in patients with no inducible WMA (p = 0.007) were seen. No significant difference was noted in GCS between rest and stress in patients with WMA (p = 0.13). There was a larger absolute GCS/GCSR at peak stress in subjects with no inducible FPP defect or WMA.

Conclusion

Smaller absolute GCS and a lack of significant change in GCS at peak stress in those with inducible WMA or perfusion defect are suggestive of compromised LV deformation in subjects with inducible WMA. Given these findings, GCS derived from CMR-FT may be used to objectively assess WMA in pediatric patients undergoing stress CMR.

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

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

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

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

Management of Adults With Anomalous Aortic Origin of the Coronary Arteries: State-of-the-Art Review

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.

[ANOCOR registry]

Anomalous aortic origin of the coronary arteries are congenital anomalies with many anatomical forms. Due to the varying risk of sudden death, these abnormalities must be classified accurately. There are still questions about the mechanism and individual risk of sudden death, the natural history of these abnormalities and the benefits of a surgical correction. Large-scale observational registries may provide more evidence-based data to practitioners caring for the patients concerned. The ANOCOR registry, the largest in size published to date, enrolled 472 patients (mean age 63 years) with 496 coronary abnormalities. The angiographic representation (with invasive coronary angiography or coronary CT angiography) according to the coronary artery and initial ectopic course could be specified with the identification of two main phenotypes: the circumflex artery (n = 235) with a retroaortic course in 97% of cases and the right coronary artery (n = 165) with an interarterial course in 89.7% of cases. Two left coronary anatomical forms have been confused by non-expert cardiologists: those with a retropulmonary or interarterial course. Sudden death related to coronary anomaly was a very rare mode of presentation (3 patients or 0.6% of the cohort) in this population with very few young patients < 35 years (11 cases or 2.3% of the cohort).

Management of Adults With Anomalous Aortic Origin of the Coronary Arteries: State-of-the-Art Review

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.

Ischemia in Anomalous Aortic Origin of a Right Coronary Artery: Large Pediatric Cohort Medium-Term Outcomes

BACKGROUND

Anomalous aortic origin of a right coronary artery may cause myocardial ischemia and sudden death in the young. Data on myocardial ischemia or longitudinal outcomes are sparse in pediatric anomalous aortic origin of a right coronary artery population.

METHODS

Patients <21 years with anomalous aortic origin of a right coronary artery were prospectively enrolled. Computerized tomography angiography defined morphology. Exercise stress test and stress perfusion imaging (sPI) were performed if >7 years or younger with concern for ischemia. High-risk features included intramural length, slit-like/hypoplastic ostium, exertional symptoms, or evidence of ischemia.

RESULTS

A total of 220 patients (60% males) were enrolled December 2012 to April 2020 at a median age 11.4 years (interquartile range, 6.1-14.5), including 168 (76%) with no/nonexertional symptoms (group 1) and 52 (24%) with exertional chest pain/syncope (group 2). Computerized tomography angiography was available in 189/220 (86%), exercise stress test in 164/220 (75%), and sPI in 169/220 (77%). Exercise stress test was positive in 2/164 (1.2%) patients in group 1, both had positive sPI. Inducible ischemia (sPI) was detected in 11/120 (9%) in group 1 and 9/49 (18%) in group 2 (P=0.09). Intramural length was similar in patients with/without ischemia (5 [interquartile range, 4-7] versus 5 [interquartile range, 4-7] mm; P=0.65). Surgery was recommended in 56/220 (26%) patients with high-risk features. In 52 surgical patients (38 unroofing, 14 reimplantation), all subjects were alive and have returned to exercise at last median follow-up of 4.6 (interquartile range, 2.3-6.5) years.

CONCLUSIONS

Anomalous aortic origin of a right coronary artery patients can present with inducible ischemia on sPI despite symptoms or intramural length. Exercise stress test is a poor predictor of ischemia and caution should be given to determine low-risk based solely on this assessment. All patients are alive at medium-term follow-up.

Coronary Stent Placement in an Interarterial Anomalous Right Coronary Artery: An Alternative Approach in a Multimorbid High-risk Surgical Patient

Anomalous aortic origin of a coronary artery is a rare congenital anomaly and potential aetiology for sudden cardiac death. However, the mere presence of this anomaly does not portend clinical significance, and there are many factors that contribute to limiting coronary blood flow in these patients. The standard of care for symptomatic individuals is surgical management with coronary unroofing although not all cases are amenable to surgery. We report the case of an anomalous right coronary artery with interarterial course managed by percutaneous coronary intervention due to surgical contraindication secondary to comorbidities. The proposed mechanism of action culminating in aborted sudden cardiac death is unique and involves aggravated pulmonary hypertension in an individual with severe comorbid pulmonary disease.

Incidental Diagnosis of Anomalous Origin of Right Coronary Artery From the Contralateral (Left) Sinus of Valsalva in a Child: Sonographer and Physician Perspectives

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Congenital CCAs are rare in children.

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Transthoracic echocardiography is the preferred imaging modality for initial diagnosis.

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Cardiovascular computed tomography is commonly used to confirm the diagnosis.

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Decision on timing of surgery in a young and asymptomatic child is often difficult.

Anomalous Coronary Arteries: When to Follow-up, Risk Stratify, and Plan Intervention

PURPOSE OF REVIEW

Coronary artery anomalies are a diverse group of entities, ranging from benign variations of normal anatomy to life-threatening conditions. There is, however, no universal consensus in their classification, risk stratification, and management. The aim of this review is to develop a straightforward clinical approach for the assessment and care of patients with anomalous coronary arteries.

RECENT FINDINGS

Autopsy series and population screening studies have recently provided useful clinical data on the prevalence and outcomes of coronary anomalies. Also, findings on coronary computed tomography angiography, magnetic resonance imaging, and invasive angiography, enriched with fractional flow reserve and intravascular ultrasound, have allowed identification of several high-risk features associated with specific coronary anomalies. Management of patients with anomalous coronary arteries requires an individualized approach based on clinical, physiological, and anatomic features. High-quality studies are paramount for further development of this fascinating field.

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

Background:

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

Methods:

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

Results:

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

Conclusion:

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

Outcomes in anomalous aortic origin of a coronary artery after surgical reimplantation

OBJECTIVE

Anomalous aortic origin of a coronary artery (AAOCA) can be associated with myocardial ischemia and sudden cardiac arrest. We compared outcomes data of patients who underwent transection and reimplantation (TAR) and patients who underwent an unroofing.

METHODS

Patients who presented to the Coronary Artery Anomalies Program were evaluated and managed following a standardized approach. Anatomy was determined using computed tomography angiography, myocardial perfusion using advanced stress imaging, and surgical intervention according to anatomic features.

RESULTS

Sixty-one patients underwent surgical repair of AAOCA between 2012 and 2019: 16 (26%) patients underwent TAR of the anomalous coronary without an aortic button and 45 (74%) patients underwent coronary unroofing. Compared with patients who underwent an unroofing, patients who underwent TAR had similar intramural length (5 mm with interquartile range of 4-7.7 vs 6 mm with interquartile range of 5-7; P = .6). One patient with an anomalous right coronary underwent coronary artery bypass grafting after TAR because of persistent postoperative ischemic changes. One patient with unroofing of an anomalous left coronary artery presented with recurrent aborted sudden cardiac death and underwent subsequent TAR, without further events. At last follow-up, 15 of 16 patients (94%) who underwent TAR and 42 of 45 (93%) patients who underwent an unroofing were released to unrestricted exercise activities.

CONCLUSIONS

Coronary artery TAR is a useful surgical alternative for AAOCA when there is a course below the commissure, when unroofing does not relocate the ostium to the appropriate sinus, or when unroofing results in compression by the intercoronary pillar.

Anomalous Aortic Origin of the Coronary Arteries - State of the Art Management and Surgical Techniques

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.

Evaluating Chest Pain and Heart Murmurs in Pediatric and Adolescent Patients

Chest pain and heart murmurs are common issues primary care providers must evaluate and manage. Both are a source of anxiety for patients, parents, and providers, necessitating evaluation and understanding to ensure appropriate management. Most pediatric chest pain can be treated symptomatically and with reassurance. This article examines the approach to pediatric chest pain including identification of key historical points, common causes of chest pain, and when to refer. The article also delineates our approach to auscultation, describes common benign murmurs, and offers suggestions on when to refer for further evaluation.

Coronary artery anomalies and dominance: data from a single center in Turkey

BACKGROUND

Coronary artery anomalies (CAA) are found in 0.2% to 1.3% of coronary angiograms. The aim of the presented study was to describe congenital CAA and their variations, also identifying the prevalence of these anomalies and coronary artery dominance in our center.

METHODS

A total of 7858 patients were included in the study retrospectively between August 2015 and March 2020. Patients undergoing coronary angiography (CAG) were reviewed by at least 2 independent and experienced observers. The Angelini's CAA Classification method was used to classify patients. Coronary dominance was determined according to the artery from which the posterior desending artery originated.

RESULTS

CAA was detected in 88 (1.1%) out of 7858 patients. Of these patients, 73 (82.9%) had anomalies of origination and course called group A, 7 (7.9%) had anomalies of intrinsic coronary arterial anatomy called group B, and 8 (9.1%) had anomalies of coronary termination called group C. Anomalous collateral vessels called group D were not detected. RCA dominance was N.=5579 (70.99%), Cx dominance was N.=1021 (12.99%), and codominancy was N.=1258 (16.01%).

CONCLUSIONS

The incidence of CAA was 1.1% in total and is compatible with other major studies. According to the Angelini CAA clasification, group B anomalies are observed more frequently than other studies. Cx dominance is moderately high.

Cardiac arrest due to an anomalous aortic origin of a coronary artery: are older patients really safe?

The authors report a rare case of successful Advanced Life Support in the context of cardiac arrest due to the presence of an anomalous aortic origin of the right coronary artery in a 49-year-old patient. The patient was admitted due to chest pain and dyspnea, with rapid evolution of pulseless ventricular tachycardia and cardiopulmonary arrest. Acute myocardial infarction was considered, and in the absence of a hemodynamic laboratory in the hospital, thrombolysis was performed. Subsequently, coronary angiography revealed no angiographic lesions in the coronary arteries and an anomalous right coronary artery originating from the opposite sinus of Valsalva. Coronary computed tomography angiography confirmed this finding and determined the course between the pulmonary artery and the aorta. The patient underwent cardiac surgery with a bypass graft to the right coronary artery, with no recurrent episodes of arrythmia.