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Anomalous communication of coronary artery — Clinical Guidelines

Overview

Anomalous communication of coronary arteries (AAOCA) refers to congenital abnormalities in the origin and course of coronary arteries, which can lead to ischemia, sudden cardiac death, and various clinical presentations depending on the specific anomaly. 1 2 6 8

Diagnosis

Key Diagnostic Criteria: Episodic symptoms such as chest pain, palpitations, and fatigue; abnormal coronary artery origin and course.

Recommended Tests:

- PET-CT Myocardial Perfusion Imaging: Useful for identifying ischemia in AAOCA patients. 1 - Fractional Flow Reserve (FFR): Invasive technique to assess functional significance of anomalous coronary arteries. 5 - Multi-Slice Computed Tomography (MSCT) Coronary Angiography: Accurate for characterizing the course of anomalous coronary arteries compared to fluoroscopic angiography. 10 - Magnetic Resonance Coronary Angiography (MRCA): Noninvasive imaging technique for identifying anomalous coronary arteries and their anatomic course. 12 - Transesophageal Echocardiography (TEE): Effective for intraoperative assessment of coronary artery reimplantation success. 8 - Biplane Coronary and Pulmonary Arteriography: Novel technique for defining complex anomalous courses, especially left main coronary artery from the right sinus of Valsalva. 11

Management

First-Line Treatments:

- Surgical Repair: Reimplantation of anomalous coronary artery onto the aorta or coronary translocation, particularly for high-risk anomalies like anomalous left coronary artery from the pulmonary artery. 2 8 17 - Percutaneous Coronary Intervention (PCI): Balloon angioplasty for stenoses at surgical conduits or anastomotic sites. 13

Adjunctive Treatments:

- External Corset Technique: For preventing aneurysmal formation at anomalous artery stumps. 3 - Medical Management: Symptomatic relief and risk factor modification (e.g., lifestyle changes, anti-ischemic medications) post-surgery. 1 6

Special Populations

Pediatrics: Surgical repair improves exercise performance and quality of life in children. 9

Comorbidities: Management strategies may vary; for instance, a Jehovah's Witness may require alternative surgical techniques avoiding blood transfusion. 2

Key Recommendations

Utilize PET-CT myocardial perfusion imaging to identify ischemia and guide treatment decisions in patients with AAOCA. (Evidence: Moderate) 1

Employ fractional flow reserve (FFR) for functional assessment of anomalous coronary arteries to guide therapeutic interventions. (Evidence: Weak) 5

Consider multi-slice computed tomography (MSCT) coronary angiography for accurate characterization of anomalous coronary artery courses compared to fluoroscopic angiography. (Evidence: Moderate) 10

Perform surgical reimplantation or coronary translocation for high-risk AAOCA anomalies to prevent sudden cardiac death and improve long-term outcomes. (Evidence: Expert opinion) 2 8 17

Evaluate pediatric patients post-surgery with exercise tests and quality of life assessments to monitor recovery and functional status. (Evidence: Moderate) 9

References

1 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. Journal of nuclear cardiology : official publication of the American Society of Nuclear Cardiology 2023. link 2 Sharma V, Doig F, Maxwell R, Grout D, Saeed U, Wall D. Anomalous Right Coronary Artery Originating From the Pulmonary Artery (ARCAPA): A Rare Presentation in the Fifth Decade. World journal for pediatric & congenital heart surgery 2023. link 3 Nakazono C, Okada S, Kato D, Uchibori A, Kanda K, Yaku H et al.. External Corset Technique in a Patient With Anomalous Artery Supply to the Left Basal Segment. The Annals of thoracic surgery 2021. link 4 Joshi SV, Naik AV, Bhalgat PS, Salvi P. Bypassing the Pump. World journal for pediatric & congenital heart surgery 2017. link 5 Boler AN, Hilliard AA, Gordon BM. Functional assessment of anomalous right coronary artery using fractional flow reserve: An Innovative Modality to Guide Patient Management. Catheterization and cardiovascular interventions : official journal of the Society for Cardiac Angiography & Interventions 2017. link 6 Green MS, Sehgal S, Smukler N, Suber LJ, Saththasivam P. Anomalous Coronary Artery: Run of a Lifetime. Seminars in cardiothoracic and vascular anesthesia 2016. link 7 Ishizawa A, Zhou M, Suzuki R, Abe H. A case of anomalous bronchial artery ramified from coronary artery. Anatomical science international 2011. link 8 de Souza DG, Blank RS, Thiele RH. Case report: transesophageal echocardiography detected severe regional wall motion abnormalities signifying failed reimplantation of an anomalous left main coronary artery. Canadian journal of anaesthesia = Journal canadien d'anesthesie 2011. link 9 Brothers JA, McBride MG, Marino BS, Tomlinson RS, Seliem MA, Pampaloni MH et al.. Exercise performance and quality of life following surgical repair of anomalous aortic origin of a coronary artery in the pediatric population. The Journal of thoracic and cardiovascular surgery 2009. link 10 Soon KH, Chaitowitz I, Selvanayagam JB, Kelly AM, Zakhem B, Nguyen M et al.. Comparison of fluoroscopic coronary angiography and multi-slice coronary angiography in the characterization of anomalous coronary artery. International journal of cardiology 2008. link 11 Wang A, Pulsipher MW, Jaggers J, Peterson GE, O'Laughlin MP, Bashore TM et al.. Simultaneous biplane coronary and pulmonary arteriography: a novel technique for defining the course of an anomalous left main coronary artery originating from the right sinus of Valsalva. Catheterization and cardiovascular diagnosis 1997. link1097-0304(199709)42:1<73::aid-ccd22>3.0.co;2-m) 12 McConnell MV, Ganz P, Selwyn AP, Li W, Edelman RR, Manning WJ. Identification of anomalous coronary arteries and their anatomic course by magnetic resonance coronary angiography. Circulation 1995. link 13 Carey D, Vincent RN, Brames GP, Williams WH, Douglas JS. Balloon angioplasty of a tissue conduit stenosis after surgical repair of anomalous left coronary artery. Catheterization and cardiovascular diagnosis 1993. link 14 Akers DL, Fowl RJ, Plettner J, Kempczinski RF. Complications of anomalous origin of the right subclavian artery: case report and review of the literature. Annals of vascular surgery 1991. link 15 Rodin AE, Singla P. Anomalous coronary artery simulating parachute mitral valve. American journal of clinical pathology 1984. link 16 Wasserman LA, Eshaghpour E, Takahashi O, Iskandrian A, Kotler MN. The noninvasive assessment of anomalous origin of the left coronary artery from the pulmonary artery. Catheterization and cardiovascular diagnosis 1979. link 17 Flemma RJ, Marx L, Litwin SB, Gallen WJ. Left ventricular aneurysmectomy in a child. Treatment of anomalous left coronary artery. The Annals of thoracic surgery 1975. link64048-9)

Anomalous communication of coronary artery