Marius R Bigler,Anselm W Stark,Federico Caobelli,Axel Rominger,Ryota Kakizaki,Flavio G Biccirè,Saddam M A Al-Sabri,Isaac Shiri,Matthias Siepe,Stephan Windecker,Lorenz Räber,Christoph Gräni
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引用次数: 0
Abstract
Importance
Right anomalous aortic origin of a coronary artery (R-AAOCA) is a rare congenital condition increasingly diagnosed with the growing use of cardiac imaging. Due to dynamic compression of the anomalous vessel, invasive fractional flow reserve (FFR) during a dobutamine-atropine volume challenge (FFR-dobutamine) is considered the reference standard. A reliable alternative method is needed to reduce extensive invasive testing, but it remains uncertain whether noninvasive imaging can accurately assess the hemodynamic relevance of R-AAOCA.
Objective
To evaluate the diagnostic performance of noninvasive anatomical and functional cardiac imaging to determine the hemodynamic relevance of R-AAOCA compared with the FFR-dobutamine reference standard.
Design, Setting, and Participants
This was a prospective, single-center cohort study performed between June 2020 and January 2025. The study was conducted at a specialized coronary artery anomaly clinic in Bern, Switzerland. Consecutive adult patients with R-AAOCA with an interarterial/intramural course and a right coronary dominance were included in the study.
Interventions
All patients underwent coronary computed tomography angiography (CCTA), nuclear cardiac imaging, and invasive FFR-dobutamine testing.
Main Outcomes and Measures
Hemodynamic relevance of the anomalous vessel was defined as an FFR-dobutamine value less than or equal to 0.8. Patients with stenotic atherosclerotic plaques in the anomalous vessel at the time of functional testing were excluded.
Results
A total of 55 patients (mean [SD] age, 51 [12] years; 37 male [67%]) with newly detected R-AAOCA and combined interarterial/intramural course were included in the analysis. Median FFR-dobutamine was 0.87 (IQR, 0.80-0.91), and 15 cases (27%) were hemodynamically relevant (ie, FFR-dobutamine ≤0.8). Anatomical CCTA (ie, CCTA-ostial minor axis) assessment demonstrated both a 100% sensitivity and negative predictive value with a receiver operating characteristic curve of 0.82, as well as a specificity of 57%, leading to rule out 23 cases (42%; ie, 58% of the hemodynamic nonrelevant cases). Functional nuclear imaging detected ischemia in 4 patients (7%; ie, 27% of hemodynamically relevant cases, all true positive, none false positive), resulting in a sensitivity of 27%, both specificity and positive predictive value of 100%, and an accuracy of 80% in predicting FFR-dobutamine less than or equal to 0.8.
Conclusions and Relevance
Results of this cohort study suggest that in adults with R-AAOCA, a multimodality diagnostic imaging approach applicable in a stepwise manner, starting with CCTA, which offers high diagnostic performance to exclude hemodynamic relevance-and optionally complemented by functional imaging with modest diagnostic performance to rule in hemodynamic relevance-may help to reduce the need for invasive testing to a subset of patients.
JAMA cardiologyMedicine-Cardiology and Cardiovascular Medicine
CiteScore
45.80
自引率
1.70%
发文量
264
期刊介绍:
JAMA Cardiology, an international peer-reviewed journal, serves as the premier publication for clinical investigators, clinicians, and trainees in cardiovascular medicine worldwide. As a member of the JAMA Network, it aligns with a consortium of peer-reviewed general medical and specialty publications.
Published online weekly, every Wednesday, and in 12 print/online issues annually, JAMA Cardiology attracts over 4.3 million annual article views and downloads. Research articles become freely accessible online 12 months post-publication without any author fees. Moreover, the online version is readily accessible to institutions in developing countries through the World Health Organization's HINARI program.
Positioned at the intersection of clinical investigation, actionable clinical science, and clinical practice, JAMA Cardiology prioritizes traditional and evolving cardiovascular medicine, alongside evidence-based health policy. It places particular emphasis on health equity, especially when grounded in original science, as a top editorial priority.