Abstract 1939: Evaluation of Myocardial Ischemia Following Surgical Repair of Anomalous Aortic Origin of a Coronary Artery from the Opposite Sinus of Valsalva in a Series of Pediatric Patients
Purpose. Anomalous aortic origin of a coronary artery (AAOCA) occurs when the left main coronary arises from the right sinus of Valsalva (ALCA) or right arises from left (ARCA). When it courses between the great arteries, sudden death risk in children is increased and surgery is recommended. Our purpose was to prospectively evaluate post-operative myocardial ischemia in the largest series of pediatric patients with interarterial AAOCA.
Methods. From 2001 to 2005, 20 children had interarterial AAOCA repair. We prospectively evaluated 15 (75%) with exercise stress tests (EST), stress echocardiograms (SE), and stress myocardial perfusion scans (MPS). Baseline clinical characteristics, presenting symptoms, and positive ischemia tests were described.
Results. The majority was male (53.3%) and had ARCA (73.3%). At diagnosis 4 of 11 ARCA patients (36.4%) were asymptomatic, 4 had chest pain (CP) with exercise, 2 had CP at rest, and 1 had pre-syncope at rest. Of 4 ALCA patients, 1 was asymptomatic, 2 had exertional syncope, and 1 had CP at rest. Median age at surgery was 12 (5–17) years; follow-up was 27 (5– 48) months. All had unobstructed neo-coronary ostia by echocardiogram. There were no sudden deaths during follow-up. No ALCA patients had evidence of post-operative ischemia. Six ARCA patients (54.5%) had positive ischemia tests. Two had inferior ST depression on stress ECG early post-operatively; subsequently, one had normal ischemia tests at 4 years but the other had anterolateral Q waves at rest 20 months post-operatively without other evidence of ischemia. Two had blunted blood pressure responses on EST with normal SE and MPS 22 and 27 months after repair. A fifth had fixed mild apical inferior hypokinesis on SE 41 months post-operatively and a sixth had a reversible perfusion defect on MPS 15 months post-operatively.
Conclusions. Subclinical changes suggestive of ischemia may occur despite patent neo-coronary ostia, notably after ARCA repair, which may be due to an inherent functional coronary abnormality. The implication of these results on indication for surgery and subsequent risk of sudden death is unknown. Serial exercise tests, stress echocardiograms, and myocardial perfusion imaging are essential in evaluating ongoing ischemia risk after AAOCA repair.