Is Exercise Stress Testing Useful for Risk Stratification in Anomalous Aortic Origin of a Coronary Artery?

Amna Qasim; Tam T Doan; Tam Dan Pham; Dana Reaves-O'Neal; Shagun Sachdeva; Carlos M Mery; Ziyad Binsalamah; Silvana Molossi

doi:10.1053/j.semtcvs.2022.08.009

Is Exercise Stress Testing Useful for Risk Stratification in Anomalous Aortic Origin of a Coronary Artery?

Semin Thorac Cardiovasc Surg. 2023;35(4):759-768. doi: 10.1053/j.semtcvs.2022.08.009. Epub 2022 Aug 28.

Authors

Amna Qasim¹, Tam T Doan², Tam Dan Pham³, Dana Reaves-O'Neal⁴, Shagun Sachdeva⁵, Carlos M Mery⁶, Ziyad Binsalamah⁷, Silvana Molossi⁸

Affiliations

¹ The Lillie Frank Abercrombie Section of Cardiology, Texas Children's Hospital, Department of Pediatrics, Baylor College of Medicine, Houston, Texas; The Coronary Artery Anomalies Program, Texas Children's Hospital, Houston, Texas. Electronic address: amnahqasim@gmail.com.
² The Lillie Frank Abercrombie Section of Cardiology, Texas Children's Hospital, Department of Pediatrics, Baylor College of Medicine, Houston, Texas; The Coronary Artery Anomalies Program, Texas Children's Hospital, Houston, Texas. Electronic address: Tam.Doan@bcm.edu.
³ The Lillie Frank Abercrombie Section of Cardiology, Texas Children's Hospital, Department of Pediatrics, Baylor College of Medicine, Houston, Texas. Electronic address: tnpham1@texaschildrens.org.
⁴ The Lillie Frank Abercrombie Section of Cardiology, Texas Children's Hospital, Department of Pediatrics, Baylor College of Medicine, Houston, Texas; The Coronary Artery Anomalies Program, Texas Children's Hospital, Houston, Texas. Electronic address: dlreave1@texaschildrens.org.
⁵ The Lillie Frank Abercrombie Section of Cardiology, Texas Children's Hospital, Department of Pediatrics, Baylor College of Medicine, Houston, Texas; The Coronary Artery Anomalies Program, Texas Children's Hospital, Houston, Texas. Electronic address: Shagun.Sachdeva@bcm.edu.
⁶ Texas Center for Pediatric and Congenital Heart Disease, University of Texas Dell Medical School, Dell Children's Medical Center, The University of Texas at Austin, Austin, Texas. Electronic address: cmery@austin.utexas.edu.
⁷ The Coronary Artery Anomalies Program, Texas Children's Hospital, Houston, Texas; Division of Congenital Heart Surgery, Michael E. DeBakey Department of Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas. Electronic address: zxbinsal@texaschildrens.org.
⁸ The Lillie Frank Abercrombie Section of Cardiology, Texas Children's Hospital, Department of Pediatrics, Baylor College of Medicine, Houston, Texas; The Coronary Artery Anomalies Program, Texas Children's Hospital, Houston, Texas. Electronic address: smolossi@bcm.edu.

PMID: 36041683
DOI: 10.1053/j.semtcvs.2022.08.009

Abstract

Data on maximal exercise-stress-testing (m-EST) in anomalous-aortic-origin-of-coronary-arteries (AAOCA) is limited and correlation with stress perfusion imaging has not been demonstrated. AAOCA patients ≤20 years were prospectively enrolled from 6/2014-01/2020. A m-EST was defined as heart rate >85%ile on ECG-EST and respiratory-exchange-ratio ≥1.05 on cardiopulmonary-exercise-testing (CPET). Abnormal m-EST included significant ST-changes or high-grade arrhythmia, V̇O_2max and/or O₂ pulse <85% predicted, or abnormal O₂ pulse curve. A (+) dobutamine-stress cardiac-magnetic-resonance-imaging (+DS-CMR) had findings of inducible-ischemia. Outcomes: (1) Differences in m-EST based on AAOCA-type; (2) Assuming DS-CMR as gold-standard for detection of inducible ischemia, determine agreement between m-EST and DS-CMR. A total of 155 AAOCA (right, AAORCA = 126; left, AAOLCA = 29) patients with a median (IQR) age of 13 (11-15) years were included; 63% were males and a m-EST was completed in 138 (89%). AAORCA and AAOLCA had similar demographic and m-EST characteristics, although AAOLCA had more frequently evidence of inducible ischemia on m-EST (P = 0.006) and DS-CMR (P = 0.007). Abnormal O₂ pulse was significantly associated with +DS-CMR (OR 5.3, 95% CI 1.6-18,P = 0.005). Sensitivity was increased with addition of CPET to ECG-EST (to 58% from 19%). There was no agreement between m-EST and DS-CMR for detection of inducible ischemia. A m-EST has very low sensitivity for detection of inducible ischemia in AAOCA, and sensitivity is increased with addition of CPET. Stress perfusion abnormalities on DS-CMR were notconcordant with m-EST findings and adjunctive testing should be considered for clinical decision making in AAOCA.

Keywords: Anomalous aortic origin of a coronary artery; Coronary anomaly; Exercise stress testing; Stress perfusion imaging.

MeSH terms

Adolescent
Coronary Vessel Anomalies* / complications
Coronary Vessel Anomalies* / diagnostic imaging
Coronary Vessels*
Exercise Test
Female
Humans
Ischemia
Male
Risk Assessment
Treatment Outcome