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Original research article
Risk stratification with exercise N13-ammonia PET in adults with anomalous right coronary arteries
  1. Paul C Cremer1,
  2. Amgad Mentias1,
  3. Srikanth Koneru1,
  4. Paul Schoenhagen1,2,
  5. David Majdalany1,
  6. Richard Lorber3,
  7. Scott D Flamm1,2,
  8. Robert E Hobbs1,
  9. Gosta Pettersson4 and
  10. Wael A Jaber1
  1. 1Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
  2. 2Cardiovascular Section, Imaging Institute, Cleveland Clinic, Cleveland, Ohio, USA
  3. 3Children's Hospital of San Antonio, Baylor College of Medicine, San Antonio, Texas, USA
  4. 4Department of Cardiothoracic Surgery, Cleveland Clinic, Cleveland, Ohio, USA
  1. Correspondence to Dr Wael A Jaber; jaberw{at}ccf.org

Abstract

Objective In adults with an interarterial and intramural course of an anomalous right coronary artery from the left sinus (AAORCA), surgical unroofing is recommended in the setting of myocardial ischaemia. However, data regarding functional testing are limited, and the management of adults without ischaemia is unclear. To evaluate these patients, we employed an exercise N13-ammonia positron emission tomography (PET) protocol. We hypothesised that patients with typical angina and exertional dyspnoea would be more likely to have ischaemia and that patients without ischaemia could be managed conservatively.

Methods Between July 2008 and December 2014, we retrospectively identified 27 consecutive patients >18 years old with an interarterial and intramural course of an AAORCA who had exercise N13-ammonia PET.

Results The majority of patients had anatomic delineation with cardiac CT (25, 93%), and most patients had chest pain (24, 89%). Myocardial ischaemia with PET was common (13, 48%), and ischaemia was more likely in patients with typical angina and exertional dyspnoea (p<0.05). Surgery was performed in 12 patients including 11 patients with ischaemia. At a median follow-up of 245 days, there were no deaths in patients with surgery or in patients managed conservatively.

Conclusions In patients with an interarterial and intramural course of an AAORCA, typical angina and exertional dyspnoea are associated with ischaemia on exercise N13-ammonia PET. Referral for surgical unroofing in symptomatic patients with ischaemia on exercise N13-ammonia PET and initial conservative management in patients without ischaemia seems appropriate, though larger studies with long-term follow-up are needed.

  • CONGENITAL HEART DISEASE

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

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