Preoperative evaluation and indication to surgery
A standardized echocardiographic protocol has been developed in these
years in our institution for the diagnosis of AAOCA [16].
Trans-thoracic echocardiography (TTE) and computed tomography scan were
performed in all patients. Echocardiographic studies were performed
using a commercially available Philips iE33 ultrasound systems (Philips
Medical Systems, Amsterdam, The Netherlands), using a 2.5 or 3.5 MHz
transducer, as appropriate. Images were acquired at a frame rate of
70–80 frames/s, applying a standard two‐dimensional greyscale. Images
of three consecutive heart cycles were collected from the parasternal
short axis (PSAX) and long‐axis (PLAX), and the 4/5-chambers apical
views. Coronary computed tomography examinations were subsequently
obtained using a 384 (192Å~2)-slices third-generation
scanner (SOMATOM Force CT; Siemens Healthineers, Forchheim, Germany).
The echocardiographic and CT images were evaluated and compared by
dedicated team including radiologists with cardiac expertise and
pediatric cardiologists with training in cardiac radiology. The images
(Figure 1) were discussed with the team of surgeons before the planning
of the operation and were re-discussed after the intra-operative
observation in order to plan future cases.
The take-off angle of the anomalous coronary was calculated on CT axial
view images, at the intersection of two lines of which one passed at the
base of the coronary artery and the other in the first 5 mm of the
vessel (Figure 2).
Indications to surgery were the presence of symptoms suggestive of
ischemia (chest pain episodes especially during efforts, syncope or
ventricular arrhythmia), the presence of an AAOLCA, the presence of an
AAORCA with anatomic features considered at high risk (inter-arterial
and long intramural course, i.e. more than 5 mm) regardless to symptoms
especially in young athletes that rejected sport restriction.