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

  • Amna Qasim
    Affiliations
    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
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  • Tam T. Doan
    Affiliations
    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
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  • Tam Dan Pham
    Affiliations
    The Lillie Frank Abercrombie Section of Cardiology, Texas Children's Hospital, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
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  • Dana Reaves-O'Neal
    Affiliations
    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
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  • Shagun Sachdeva
    Affiliations
    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
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  • Carlos M. Mery
    Affiliations
    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
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  • Ziyad Binsalamah
    Affiliations
    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
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  • Silvana Molossi
    Correspondence
    Address reprint requests to Silvana Molossi, MD, PhD, Texas Children's Hospital, Baylor College of Medicine, 6651 Main St, MC E1920, Houston, TX 77030.
    Affiliations
    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
    Search for articles by this author
      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, V̇O2max 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 not concordant with m-EST findings and adjunctive testing should be considered for clinical decision making in AAOCA.

      Graphical abstract

      Keywords

      Abbreviations:

      AAOCA (anomalous aortic origin of a coronary artery (right AAORCA left AAOLCA)), CPET (cardiopulmonary exercise stress test), DS-CMR (dobutamine stress-cardiac magnetic resonance imaging), ECG-EST (electrocardiographic evaluation of exercise stress test), LAD (left anterior descending), m-EST (maximal-exercise stress test), O2 pulse (oxygen pulse), RER (respiratory exchange ratio), VAT (ventilatory anaerobic threshold), V̇E/V̇CO2 (minute ventilation/carbon dioxide production), V̇O2 (maximal oxygen uptake)
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