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Leone D, Buber J, Shafer K. Exercise as Medicine: Evaluation and Prescription for Adults with Congenital Heart Disease. Curr Cardiol Rep 2023; 25:1909-1919. [PMID: 38117446 DOI: 10.1007/s11886-023-02006-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/22/2023] [Indexed: 12/21/2023]
Abstract
PURPOSE OF REVIEW Understanding exercise physiology as it relates to adult congenital heart disease (ACHD) can be complex. Here we review fundamental physiologic principles and provide a framework for application to the unique ACHD patient population. RECENT FINDINGS ACHD exercise participation has changed dramatically in the last 50 years. A modern approach focuses on exercise principles and individual anatomic and physiologic considerations. With an evolving better understanding of ACHD exercise physiology, we can strategize plans for patients to participate in dynamic and static exercises. Newly developed technologies including wearable devices provide additive information for ACHD providers for further assessment and monitoring. Preparation and assessment for ACHD patients prior to exercise require a thoughtful, personalized approach. Exercise prescriptions can be formulated to adequately meet the needs of our patients.
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Affiliation(s)
- David Leone
- Division of Cardiology, University of Washington, Seattle, WA, USA
| | - Jonathan Buber
- Division of Cardiology, University of Washington, Seattle, WA, USA
| | - Keri Shafer
- Boston Children's Hospital, Boston, MA, USA.
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2
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Lau WR, Lee PT, Koh CH. Coronary Artery Anomalies - State of the Art Review. Curr Probl Cardiol 2023; 48:101935. [PMID: 37433414 DOI: 10.1016/j.cpcardiol.2023.101935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 07/04/2023] [Indexed: 07/13/2023]
Abstract
Coronary artery anomalies (CAAs) comprise a wide spectrum of anatomic entities, with diverse clinical phenotypes. We present a case of an anomalous right coronary artery arising from the left aortic sinus with an interarterial course, a potentially fatal condition that can precipitate ischemia and sudden cardiac death. CAAs are increasingly detected in adults, mostly as incidental findings in the course of cardiac evaluation. This is due to the expanding use of invasive and noninvasive cardiac imaging, usually in the work-up for possible CAD. The prognostic implications of CAAs in this group of patients remain unclear. In AAOCA patients, appropriate work-up with anatomical and functional imaging should be performed for risk stratification. An individualized approach to management should be adopted, considering symptoms, age, sporting activities and the presence of high-risk anatomical features and physiologic consequences (such as ischemia, myocardial fibrosis, or cardiac arrhythmias) detected on multimodality imaging or other functional cardiac investigations. This comprehensive and up to date review seeks to crystallize current data in the recent literature, and proposes a clinical management algorithm for the clinician faced with the conundrum of managing such conditions.
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Affiliation(s)
- Wei Ren Lau
- Department of Cardiology, National Heart Centre Singapore, Singapore
| | - Phong Teck Lee
- Department of Cardiology, National Heart Centre Singapore, Singapore; Duke-NUS School of Medicine, National University of Singapore, Singapore
| | - Choong Hou Koh
- Department of Cardiology, National Heart Centre Singapore, Singapore; Duke-NUS School of Medicine, National University of Singapore, Singapore; Changi Aviation Medical Centre, Changi General Hospital, Singapore.
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3
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Dong T, Wang TKM, Cremer P, Najm HK, Jaber W. A story of resolved ischemia from anomalous coronary arteries as told by PET/CT. J Nucl Cardiol 2023; 30:1725-1729. [PMID: 35851644 DOI: 10.1007/s12350-022-03055-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 05/07/2022] [Indexed: 10/17/2022]
Affiliation(s)
- Tiffany Dong
- Section of Cardiovascular Imaging, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Tom Kai Ming Wang
- Section of Cardiovascular Imaging, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Paul Cremer
- Section of Cardiovascular Imaging, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Hani K Najm
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Wael Jaber
- Section of Cardiovascular Imaging, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA.
- Section of Cardiovascular Imaging, Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart and Vascular Institute, Cleveland Clinic Main Campus J1-5, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.
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Lima BB, Cuddy SAM. Myocardial perfusion imaging in anomalous coronary arteries: do we know who to refer for cardiac surgery? J Nucl Cardiol 2023; 30:790-791. [PMID: 36369626 DOI: 10.1007/s12350-022-03127-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 09/22/2022] [Indexed: 11/13/2022]
Affiliation(s)
- Bruno B Lima
- Division of Cardiovascular Imaging, Department of Radiology, Brigham and Women's Hospital, 15 Francis Street, Boston, MA, 02116, USA
| | - Sarah A M Cuddy
- Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, 15 Francis Street, Boston, MA, 02116, USA.
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Wang TKM, Dong T, Cremer PC, Najm H, Pettersson G, Jaber WA. Utility of positron emission tomography myocardial perfusion imaging for identifying ischemia and guiding treatment in patients with anomalous coronary arteries. J Nucl Cardiol 2023; 30:781-789. [PMID: 35978070 PMCID: PMC9385075 DOI: 10.1007/s12350-022-03071-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Accepted: 07/06/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND The assessment of anomalous coronary arteries (AAOCA) remains controversial without an optimal stress modality for ischemia. We evaluated the value of PET-CT myocardial perfusion imaging in these patients and subsequent management. METHODS AND RESULTS AAOCA patients (n = 82) undergoing PET-CT from 2015 to 2021 were retrospectively chart reviewed. Multivariable analyses performed to assess relevant clinical and imaging factors associated with ischemia on PET and AAOCA surgery. Key characteristics include mean age 45 ± 20 years, 30 (37%) female, 45 (55%) with chest pain, 19 (23%) anomalous left main coronary artery, 58 (71%) anomalous right coronary artery, 26 (32%) with objective ischemia on PET-CT, and 37 (45%) who underwent AAOCA surgery. Adverse outcomes over mean follow-up of 2.2 ± 1.8 years included one death and two myocardial infarctions. Anomalous left main was independently associated with ischemia on PET-CT, odds ratio (95% confidence intervals) 4.15 (1.31-13.1), P = .006. Chest pain and ischemia on PET-CT were independently associated with and provided incremental prognostic value for surgery, odds ratio 9.73 (2.78-34.0), P < .001 and 6.79 (1.99-23.2), P = .002, respectively. CONCLUSION Ischemia on PET-CT occurred in a third of our cohort, identifying patients who may benefit from surgery. Larger studies are needed to evaluate the interplay between AAOCA, ischemia by PET and surgery.
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Affiliation(s)
- Tom Kai Ming Wang
- Section of Cardiovascular Imaging, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Tiffany Dong
- Section of Cardiovascular Imaging, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Paul C Cremer
- Section of Cardiovascular Imaging, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Hani Najm
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Gosta Pettersson
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Wael A Jaber
- Section of Cardiovascular Imaging, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA.
- Section of Cardiovascular Imaging, Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart and Vascular Institute, Cleveland Clinic, Main Campus J1-5, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.
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6
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Abstract
Exercise stress testing (EST) is indicated for diagnostic and prognostic purposes in the general population. In athletes, stress tests can also be useful to inform the risk of high-intensity training and competition, to assess athletic conditioning, and to refine training regimens. Many specific indications for EST are unique to athletes. Treadmill and cycle ergometer protocols each have their strengths and disadvantages; extensive protocol customization may be necessary to answer the clinical question at hand. A comprehensive understanding of the available tools for exercise testing, their strengths, and their limitations is crucial to providing cardiovascular care to athletic individuals.
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Affiliation(s)
- Gary Parizher
- Sports Cardiology Center, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Michael S Emery
- Sports Cardiology Center, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA.
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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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Anomalous Aortic Origin of a Coronary Artery in Adults. Ann Thorac Surg 2020; 112:1299-1305. [PMID: 33279536 DOI: 10.1016/j.athoracsur.2020.06.153] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Revised: 06/04/2020] [Accepted: 06/29/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND Anomalous aortic origin of a coronary artery (AAOCA) is the second leading cause of sudden death in youth. However, its significance and optimal management in adults is poorly understood. Our objective is to characterize AAOCA in a large single-center adult cohort based on coronary anatomic variants and surgical management strategies. METHODS We reviewed imaging, clinic, and operative reports for 645 adults with an encounter diagnosis code of congenital coronary anomaly from July 2015 to July 2017. After excluding other congenital heart defects, we characterized 167 patients with AAOCAs by anatomic variant, symptoms at diagnosis, indication for advanced imaging, and if performed, surgical repair. To describe the anatomic variant, we classified the origin and course by following the atomization scheme developed by the Congenital Heart Surgeon's Society's AAOCA registry. RESULTS Among adults with AAOCA, the anomalous origin involved the right coronary artery in 57% (96 of 167), left main coronary artery in 23% (39 of 167), left anterior descending in 2% (4 of 167), circumflex in 16% (26 of 167), and multiple coronaries in 1% (2 of 167). Anomalous right coronary arteries were diagnosed at an older median age than anomalous left main coronary arteries (55 vs 51 years, respectively; P = .026). Surgical repair of AAOCA occurred in 22% (36 of 167) of patients. Concomitant cardiac surgical procedures accompanied 36% (13 of 36) of them. No deaths occurred over a median follow-up of 2.5 years. CONCLUSIONS Most patients in our single-center AAOCA registry were diagnosed in the presence of cardiac symptoms. Concomitant aortic valve disease and coronary atherosclerotic burden complicate both the evaluation and surgical approach to adult AAOCA repair.
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Fares M, Critser PJ, Arruda MJ, Wilhelm CM, Rattan MS, Lang SM, Alsaied T. Pharmacologic stress cardiovascular magnetic resonance in the pediatric population: A review of the literature, proposed protocol, and two examples in patients with Kawasaki disease. CONGENIT HEART DIS 2019; 14:1166-1175. [PMID: 31498562 DOI: 10.1111/chd.12840] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 08/13/2019] [Accepted: 08/29/2019] [Indexed: 12/01/2022]
Abstract
Pharmacologic stress cardiovascular magnetic resonance (PSCMR) is a well-established and reliable diagnostic tool for evaluation of coronary artery disease in the adult population. Stress imaging overall and PSCMR in particular is less utilized in the pediatric population with limited reported data. In this review, we highlight the potential use of PSCMR in specific pediatric cohorts with congenital and acquired heart disease, and we review the reported experience. A suggested protocol is presented in addition to two case examples of patients with Kawasaki disease where PSCMR aided decision making.
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Affiliation(s)
- Munes Fares
- Division of Pediatric Cardiology, UH Rainbow Babies & Children's Hospital, Cleveland, Ohio
| | - Paul J Critser
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Maria J Arruda
- Division of Pediatric Cardiology, UH Rainbow Babies & Children's Hospital, Cleveland, Ohio
| | - Carolyn M Wilhelm
- Division of Pediatric Cardiology, UH Rainbow Babies & Children's Hospital, Cleveland, Ohio
| | - Mantosh S Rattan
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Sean M Lang
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Faculty of Medicine, Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio
| | - Tarek Alsaied
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Faculty of Medicine, Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio
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Inferior Wall Myocardial Infarction in the Setting of a High-Risk Anomalous Right Coronary Artery: A Case Report. ACTA ACUST UNITED AC 2019; 3:120-124. [PMID: 31286092 PMCID: PMC6588794 DOI: 10.1016/j.case.2019.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Patients with anomalous coronary arteries rarely present with acute STEMI. Cross-sectional imaging can appropriately characterize anomalous coronary arteries. TEE may reveal physiologic features of anomalous coronary arteries.
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Summers MR, Najm H, Gentry Iii JL, Jaber WA. Exercise N-13 cardiac positron emission tomography myocardial perfusion imaging detecting ischemia in an adult patient with anomalous aortic origin of the left main coronary artery from the right coronary sinus. J Nucl Cardiol 2018; 25:1415-1417. [PMID: 28707262 DOI: 10.1007/s12350-017-0983-z] [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] [Received: 06/16/2017] [Accepted: 06/16/2017] [Indexed: 10/19/2022]
Abstract
Anomalous aortic origin of a coronary artery is a rare congenital condition that has variable presentations from atypical chest pain to syncope and cardiac arrest. Commonly used myocardial perfusion imaging techniques, stress agents, and perfusion agents may have limited ability to detect inducible ischemia in this rare patient group. We herein describe a unique case of anomalous left main coronary artery from a common right coronary sinus ostium with a subpulmonic and intramyocardial course. This patient had multiple atypical chest pain presentations and multiple-negative pharmacologic single-photon emission-computed tomography stress tests performed. Significant ischemia was detected via N-13 exercise cardiac positron emission tomography and with surgical intervention she had resolution of her symptoms.
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Affiliation(s)
- Matthew R Summers
- Robert and Suzanne Tomisch Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, J1-5, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.
| | - Hani Najm
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - James L Gentry Iii
- Robert and Suzanne Tomisch Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, J1-5, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Wael A Jaber
- Robert and Suzanne Tomisch Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, J1-5, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
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12
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Sperry BW, Jaber WA, Rodriguez LL, Pettersson G, Majdalany D. Ammonia PET imaging in young people with angina. J Nucl Cardiol 2017; 24:1822-1826. [PMID: 27743300 DOI: 10.1007/s12350-016-0699-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Revised: 09/17/2016] [Accepted: 09/19/2016] [Indexed: 10/20/2022]
Affiliation(s)
- Brett W Sperry
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA.
| | - Wael A Jaber
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - L Leonardo Rodriguez
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Gosta Pettersson
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - David Majdalany
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA
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