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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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Zhen Z, Dong Z, Na J, Chen X, Li Q, Gao L, Yuan Y. Clinical analysis of sixty-nine children with anomalous aortic origin of the coronary artery. Eur J Pediatr 2023; 182:4163-4171. [PMID: 37436520 PMCID: PMC10570235 DOI: 10.1007/s00431-023-05075-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 06/08/2023] [Accepted: 06/19/2023] [Indexed: 07/13/2023]
Abstract
We aimed to analyse the clinical characteristics of children with different types of anomalous aortic origin of the coronary artery (AAOCA) at different ages, and to discuss the factors related to myocardial ischaemia. In this retrospective study, we included 69 children diagnosed with AAOCA using CT coronary angiography; we classified the participants based on the type of AAOCA, age, and high-risk anatomy. The clinical characteristics of the different AAOCA types and age groups were compared, and the correlation between manifestations and high-risk anatomy was analysed. Anomalous origin of the left coronary artery from the right coronary artery sinus, anomalous origin of the right coronary artery from the left coronary artery sinus, and a coronary artery origin without coronary sinuses was found in 10 (14.5%), 57 (82.6%), 2 (2.9%) patients, respectively. There were no significant differences in sex, clinical manifestations, percentage of positive myocardial injury markers, electrocardiogram, transthoracic echocardiography, or proportion of high-risk anatomy among the groups with different AAOCA types. According to age group, the proportion of asymptomatic infants and pre-schoolers was the highest (p < 0.001). Forty-three patients (62.3%) had high-risk anatomy and were more likely to present with severe symptoms and cardiac syncope (p < 0.05). Conclusion: There were no significant differences in the proportions of high-risk anatomy and clinical characteristics among children with different AAOCA types. We found a relation between the severity of AAOCA clinical symptoms and anatomical risk. What is Known: • Clinical symptoms in children with AAOCA are varied and the results of routine cardiological examinations lack specificity. • High-risk anatomical features, exercise, cardiac symptoms, and ALCA are risk factors for the occurrence of SCD in patients with AAOCA. What is New: • Compared the clinical characteristics of different types of AAOCA and ages. • Analysed the correlation between symptoms and high-risk anatomical features.
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Affiliation(s)
- Zhen Zhen
- Department of Cardiology, Beijing Children's Hospital, Capital Medical University, National Centre for Children's Health, 56 South Lishi Road, Beijing, 100045, China
| | - Ziyan Dong
- Department of Cardiology, Beijing Children's Hospital, Capital Medical University, National Centre for Children's Health, 56 South Lishi Road, Beijing, 100045, China
| | - Jia Na
- Department of Cardiology, Beijing Children's Hospital, Capital Medical University, National Centre for Children's Health, 56 South Lishi Road, Beijing, 100045, China
| | - Xi Chen
- Department of Cardiology, Beijing Children's Hospital, Capital Medical University, National Centre for Children's Health, 56 South Lishi Road, Beijing, 100045, China
| | - Qirui Li
- Department of Cardiology, Beijing Children's Hospital, Capital Medical University, National Centre for Children's Health, 56 South Lishi Road, Beijing, 100045, China
| | - Lu Gao
- Department of Cardiology, Beijing Children's Hospital, Capital Medical University, National Centre for Children's Health, 56 South Lishi Road, Beijing, 100045, China
| | - Yue Yuan
- Department of Cardiology, Beijing Children's Hospital, Capital Medical University, National Centre for Children's Health, 56 South Lishi Road, Beijing, 100045, China.
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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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Krishnamurthy R, Masand PM, Jadhav SP, Molossi S, Zhang W, Agrawal HM, Mery CM. Accuracy of computed tomography angiography and structured reporting of high-risk morphology in anomalous aortic origin of coronary artery: comparison with surgery. Pediatr Radiol 2021; 51:1299-1310. [PMID: 33755749 DOI: 10.1007/s00247-021-05011-0] [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: 08/07/2020] [Revised: 12/13/2020] [Accepted: 02/08/2021] [Indexed: 01/12/2023]
Abstract
BACKGROUND Morphological features including interarterial course, intramural course, high ostial location and slit-like ostium are presumed risk factors for sudden cardiac death in children with anomalous aortic origin of the coronary artery (AAOCA). To facilitate clinical risk stratification, the diagnostic accuracy of CT angiography for individual risk factors in the setting of AAOCA must be established. OBJECTIVE We assessed diagnostic accuracy of standardized CT angiography interpretation for morphological characteristics that might determine risk in children with AAOCA by comparing them to surgical findings. MATERIALS AND METHODS We created a standardized protocol for CT angiography of AAOCA and retrospectively evaluated diagnostic performance in 25 consecutive surgical patients. Relevant morphological variables in AAOCA were assessed by three independent blinded readers, with surgery as the reference standard. We used Cohen kappa coefficients and accuracies to assess agreement between readers and surgical findings, and we calculated intraclass correlation coefficients to compare length of the intramural course. RESULTS CT angiography correctly identified AAOCA in all patients. For the three readers, accuracies for detecting ostial stenosis were 84%, 94% and 96%; for high ostial origin, accuracies were 76%, 78% 82%; for intramurality using the peri-coronary fat sign, accuracies were 98%, 96% and 92%; and for intramurality using oval shape of coronary artery, accuracies were 98%, 94% and 92%. The intraclass correlation coefficients (ICCs) for predicting intramural length among the three readers were 0.67, 0.75 and 0.81 using peri-coronary fat, and 0.69, 0.50 and 0.81 using oval shape, respectively. CONCLUSION CT angiography reliably identified AAOCA in all children and detected the presence of intramurality with high accuracy.
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Affiliation(s)
- Rajesh Krishnamurthy
- Department of Radiology, Nationwide Children's Hospital, The Ohio State University, 700 Children's Drive, Columbus, OH, 43205, USA.
| | - Prakash M Masand
- Department of Pediatric Radiology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Siddharth P Jadhav
- Department of Pediatric Radiology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Silvana Molossi
- Coronary Anomalies Program, The Lillie Frank Abercrombie Section of Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Wei Zhang
- Department of Biostatistics and Data Science, University of Texas Health Science Center School of Public Health, Houston, TX, USA
| | - Hitesh M Agrawal
- Pediatric Cardiology, Pediatric & Congenital Cardiology Associates of Texas, Austin, TX, USA
| | - Carlos M Mery
- Texas Center for Pediatric and Congenital Heart Disease, University of Texas Dell Medical School/Dell Children's Medical Center, Austin, TX, USA
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Gaillard M, Pontailler M, Danial P, Moreau de Bellaing A, Gaudin R, du Puy-Montbrun L, Murtuza B, Haydar A, Malekzadeh-Milani S, Bonnet D, Vouhé P, Raisky O. Anomalous aortic origin of coronary arteries: an alternative to the unroofing strategy. Eur J Cardiothorac Surg 2021; 58:975-982. [PMID: 32572445 DOI: 10.1093/ejcts/ezaa129] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 02/11/2020] [Accepted: 03/10/2020] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVES Anomalous aortic origin of a coronary artery (AAOCA) is the second leading cause of sudden death in children and young adults. The most threatening anatomy is an interarterial and an intramural course, both probably involved in ischaemic phenomena and sudden death. The treatment of interarterial AAOCA remains controversial. Most of the published studies describe the results of the unroofing technique. Our study aims to evaluate the results of a different surgical approach. METHODS From 2005 to 2019, 61 patients were operated on for an interarterial AAOCA (median age 14.7 years). Forty patients had a right AAOCA, and 21 patients had a left AAOCA including 5 patients with intraseptal course. Seventy percent of patients were symptomatic. Five patients had an aborted sudden cardiac death. Two surgical techniques were used: an 'anatomical' repair for 35 patients (15 left and 22 right AAOCA) or a coronary translocation with creation of a neo-ostia in 19 patients (1 left and 18 right AAOCA). The 5 left AAOCA patients with an intra-septal course required a complete release of the coronary artery from the septum. RESULTS There was no early or late postoperative death. Three patients had an acute postoperative ischaemic event. Two patients required immediate angioplasty and stenting: 1 patient (7 years) with a hypoplastic right AAOCA and 1 patient (66 years) for inadequate tailoring after septal release. The third patient required an immediate surgical revision (H-2) for left AAOCA thrombosis at the level of the pericardial patch with full myocardial recovery at discharge. During follow-up, 1 patient with right AAOCA translocation and chronic chest pain required subsequent stenting and finally a coronary artery bypass grafting 2 years after initial surgery. One patient who had an asymptomatic mild right coronary stenosis 1 year after anatomical repair was successfully treated by angioplasty alone. All patients but 1 who underwent coronary translocation are totally asymptomatic. All patients with anatomical repair or septal release are free from ischaemic symptoms. CONCLUSIONS Anatomical repair might provide a better protective option for these patients. Unlike unroofing, it treats the entire intramural segment, relocates the ostium at the appropriate sinus level and corrects any acute take-off angle.
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Affiliation(s)
- Maïra Gaillard
- Department of Pediatric Cardiac Surgery, Necker Sick Children Hospital and University Paris Descartes, Paris, France
| | - Margaux Pontailler
- Department of Pediatric Cardiac Surgery, Necker Sick Children Hospital and University Paris Descartes, Paris, France
| | - Pichoy Danial
- Department of Pediatric Cardiac Surgery, Necker Sick Children Hospital and University Paris Descartes, Paris, France
| | - Anne Moreau de Bellaing
- Department of Pediatric Cardiac Surgery, Necker Sick Children Hospital and University Paris Descartes, Paris, France
| | - Régis Gaudin
- Department of Pediatric Cardiac Surgery, Necker Sick Children Hospital and University Paris Descartes, Paris, France
| | - Leonora du Puy-Montbrun
- Department of Pediatric Cardiac Surgery, Necker Sick Children Hospital and University Paris Descartes, Paris, France
| | - Bari Murtuza
- Department of Pediatric Cardiac Surgery, Necker Sick Children Hospital and University Paris Descartes, Paris, France
| | - Ayman Haydar
- Department of Pediatric Cardiac Surgery, Necker Sick Children Hospital and University Paris Descartes, Paris, France
| | - Sophie Malekzadeh-Milani
- Department of Pediatric Cardiology, Necker Sick Children Hospital-M3C and University Paris Descartes, Paris, France
| | - Damien Bonnet
- Department of Pediatric Cardiology, Necker Sick Children Hospital-M3C and University Paris Descartes, Paris, France
| | - Pascal Vouhé
- Department of Pediatric Cardiac Surgery, Necker Sick Children Hospital and University Paris Descartes, Paris, France
| | - Olivier Raisky
- Department of Pediatric Cardiac Surgery, Necker Sick Children Hospital and University Paris Descartes, Paris, France
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Lo Rito M, Romarowski RM, Rosato A, Pica S, Secchi F, Giamberti A, Auricchio F, Frigiola A, Conti M. Anomalous aortic origin of coronary artery biomechanical modeling: Toward clinical application. J Thorac Cardiovasc Surg 2020; 161:S0022-5223(20)32430-2. [PMID: 32950237 DOI: 10.1016/j.jtcvs.2020.06.150] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 05/30/2020] [Accepted: 06/05/2020] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Anomalous aortic origin of the coronary artery can be associated with sudden cardiac death and ischemic events. Anatomic static characteristics mainly dictated surgical indications, although adverse events are usually related to dynamic physical effort. We developed a computational model able to simulate anomalous coronary behavior, and we aimed to assess its clinical applicability and to investigate coronary characteristics at increasing loading stress conditions. METHODS We selected 5 patients with anomalous aortic origin of the coronary artery and 5 control subjects. For each of them, we construct a 3-dimensional model resembling the aortic root and coronary arteries based on 25 parameters obtained from computed tomography. Structural finite element analysis simulations were run to simulate pressure increasing in the aortic root during exercise (+40 mm Hg, +100 mm Hg with respect baseline condition, assumed at 80 mm Hg) and investigate coronary lumen characteristics. RESULTS The 25 parameters were obtainable in all subjects with a consistent interobserver agreement. In control subjects, the right coronary artery had a more significant lumen expansion at loading conditions compared with anomalous aortic origin of coronary artery (6%-19.2% vs 1.8%-8.1%, P = .008), which also showed an inability to expand within the intramural segment. CONCLUSIONS The proposed anomalous aortic origin of coronary artery model is able to represent the pathogenic disease mechanism after being populated with patient-specific data. It can assess the impaired expansion of anomalous right coronary at loading conditions, a process that cannot be quantified in any clinical set-up. This first clinical application showed promising results on quantifying pathological behavior, potentially helping in patient-specific risk stratification.
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Affiliation(s)
- Mauro Lo Rito
- Department of Congenital Cardiac Surgery, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy.
| | | | - Antonio Rosato
- Department of Civil Engineering and Architecture, University of Pavia, Pavia, Italy
| | - Silvia Pica
- Multimodality Cardiac Imaging Section, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Francesco Secchi
- Unit of Radiology, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Alessandro Giamberti
- Department of Congenital Cardiac Surgery, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Ferdinando Auricchio
- Department of Civil Engineering and Architecture, University of Pavia, Pavia, Italy
| | - Alessandro Frigiola
- Department of Congenital Cardiac Surgery, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Michele Conti
- Department of Civil Engineering and Architecture, University of Pavia, Pavia, Italy
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