Echocardiographic Screening of Anomalous Origin of Coronary Arteries in Athletes with a Focus on High Take-Off

Massimiliano Cantinotti,Martin Koestenberger,Eliana Franchi,Nadia Assanta,Flavio D’Ascenzi,Pietro Marchese,Raffaele Giordano,Alberto Clemente,Shelby Kutty

doi:10.3390/healthcare9020231

Abstract

Anomalous aortic origin of coronary arteries (AAOCA) represents a rare congenital heart disease. However, this disease is the second most common cause of sudden cardiac death in apparently healthy athletes. The aim of this systematic review is to analyze the feasibility and the detection rate of AAOCA by echocardiography in children and adults. A literature search was performed within the National Library of Medicine using the following keywords: coronary artery origin anomalies and echocardiography; then, the search was redefined by adding the keywords: athletes, children, and high take-off. Nine echocardiographic studies investigating AAOCA and a total of 33,592 children and adults (age range: 12–49 years) were included in this review. Of these, 6599 were athletes (12–49 years). All studies demonstrated a high feasibility and accuracy of echocardiography for the evaluation of coronary arteries origin as well as their proximal tracts. However, some limitations exist: the incidence of AAOCA varied from 0.09% to 0.39% (up to 0.76%) and was lower than described in computed tomography series (0.3–1.8%). Furthermore, echocardiographic views for the evaluation of AAOCA and the definition of “minor” defects (e.g., high take-off coronary arteries) have not been standardized. An echocardiographic protocol to diagnose the high take-off of coronary arteries is proposed in this article. In conclusion, the screening of AAOCA by echocardiography is feasible and accurate when appropriate examinations are performed; however, specific acoustic windows and definitions of defects other than AAOCA need to be standardized to improve sensitivity and specificity.

Highlights

Thirty-five studies were excluded based on the criteria listed above: 9 evaluated children with congenital heart defects (CHDs); 25 were focused on ALCAPA, Kawasaki or fistula; 10 used CT or Cardiac Magnetic Resonance (CMR) imaging; 3 were written in languages other than English
Nine articles were included in the final analysis [13,15,19,20,21,22,23,24,31], for a total of 33,592 children and adults where Anomalous aortic origin of coronary arteries (AAOCA) have been systematically screened by echocardiography (Table 1)
The use of systematic protocols including different acoustic windows in addition to a basic short-axis view is essential for the optimization of imaging for congenital coronary artery anomalies and for improving their detection by echocardiography which, at present, remains suboptimal compared to other imaging modalities such as Coronary Computed Tomography Angiography (CCTA) or CMR

Summary

Introduction

The interest in the noninvasive evaluation of anomalous aortic origin of coronary arteries (AAOCA) has increased and multiple imaging, surgical and autoptic studies have been published [1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23]. Recommendations for multimodality imaging of congenital coronary artery anomalies have been recently published (March 2020) [26], supporting the use of echocardiography as first-line imaging modality to detect AAOCAs. echocardiography may have limitations in the diagnosis of coronary defects due to technical issues such as interference by the ribs and lung, the high heart rate in neonates and children, and a poor acoustic window in some individuals [26]. Underestimated and often unknown high take-offs merit attention since these may be a cause of SCD in athletes [26,33]

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