Utility of Multimodality Imaging in the Morphologic Characterization of Anomalous Aortic Origin of a Coronary Artery

Abstract

The combination of echocardiography and CT characterizes morphologic features of anomalous origin of the coronary artery more reliably than either modality alone.

Expert consensus guidelines: Anomalous aortic origin of a coronary artery

“…The best method for initially identifying AAOCA is a carefully performed transthoracic echocardiogram with Doppler color flow mapping. 11,27,32,[53][54][55][56][57][58][59][60][61][62][63][64][65] This is generally the initial diagnostic modality due to availability, cost-effectiveness, ease of performance, and absence of radiation exposure. Imaging should clarify origin of left or right, as well as the presence or absence of an intramural course.…”

“…64 Coronary CT angiography or cardiac MRI is commonly used to obtain better visualization of the coronary artery anatomy to confirm the diagnosis. 40,46,52,59,63, Once the anatomy has been established, a maximal exercise stress test should be used to help assess the potential ischemic burden of the anatomic variant, especially in competitive athletes or high-intensity recreational athletes. We also recommend that the exercise test be combined with a nuclear perfusion scan or stress echocardiogram to optimize the sensitivity of identifying ischemia 27,32,40,[96][97][98][99] ; however, it must be emphasized that a normal stress test, nuclear perfusion scan, or stress echocardiogram is, at best, incompletely reassuring.…”

“…Additional imaging studies, such as coronary CT angiography or cardiac MRI are reasonable to better visualize the coronary artery anatomy and to confirm the diagnosis. (Class IIa, Level of Evidence B-supporting references 40,46,52,59,63,67,[69][70][71][72][73][74][75][76][77][78][79][80][81][82][83][84][85][86][87][89][90][91][92][93][94][95]100 ) 3. In those individuals without a history of ischemic chest pain or aborted SCD, exercise stress testing combined with nuclear perfusion scan or echocardiographic imaging should be used to help assess the potential ischemic burden of the anatomic variant.…”

Recommendations for Multimodality Assessment of Congenital Coronary Anomalies: A Guide from the American Society of Echocardiography

“…40 It is important to remember, however, that no imaging modality defines the histologic diagnosis of a shared tunica media. Ostial stenosis with AAOCA is frequently a concern, but despite reports that this can be identified by Doppler echocardiography, 47 this is very challenging to diagnose using echocardiography because of the need to use lower Nyquist limits for CA flow assessment, and so other imaging modalities are generally utilized to make that assessment. An intraconal CA course can be identified by visualization of the CA within the muscular conal septum inferior to the pulmonary valve annulus in subcostal and parasternal views ( Figure 8A-C); these intraconal and interarterial AAOCAs usually arise from a single coronary orifice (usually a single right CA).…”

Surgical management of anomalous coronary arteries

“…With respect to AAOCA with an inter-arterial course (i.e., between the aorta and the PA), there are certain additional details of morphology that may be associated with increased risk of ischemic events. These include the presence of an intramural segment (and possibly the length of the intramural segment), abnormally high take-off from the aorta, slit-like orifice, acute angulation of the proximal segment and an exaggerated degree of "ellipticity" (i.e., non-roundness) of the proximal segment of the coronary artery (16,17). Conversely, within the entire spectrum of AAOCA with "wrong sinus origin", there are a number of variants that are thought to be relatively benign (e.g., AAOCA with posterior looping course or anterior "prepulmonic course") as well as AAOLCA with "intra-septal" or "intraconal" courses, which have traditionally been thought of as "low risk", but this potentially requires reevaluation.…”