New Protocols Needed for Risk Stratification of Anomalous Aortic Origin of a Coronary Artery

A review of institutional echocardiographic reports suggests a need for new risk stratification protocols for anomalous aortic origin of a coronary artery.

Discrepancies between institutional reports and imaging core laboratory review for anomalous aortic origin of a coronary artery (AAOCA) calls for imaging protocol that includes risk stratification and surgical planning, according to research published in the Journal of the American College of Cardiology.

AAOCA can cause sudden death in a young population, particularly in athletes under the age of 30.  Risk factors include coronary arterial ostial stenosis, intramural course of the proximal coronary within the aortic wall, interarterial course leading to potential compression between the great arteries.

There are very few protocols in place that are effective at diagnosing these risk factors, which makes it difficult to predict an individual’s AAOCA risk based on evidence and planned surgical strategy.

“Management decisions regarding patients with AAOCA should be guided by evidence-based risk stratification, which in turn depends on accurate ascertainment of morphologic and functional details of the spectrum of anomalies, and correlation between these features and the outcomes of various treatment strategies,” the authors wrote.

A total of 159 patients with AAOCA were evaluated using data from transthoracic echocardiography (TTE) images. Percentages of missing data were calculated in the institutional echocardiographic reports of a prescribed set of anatomic AAOCA features. 

Researchers evaluated the agreement between the institutional echocardiographic report, ICL reviews, and surgical reports with weighted kappa statistics. To reduce differences between the institutional reports and ICL reviews, they developed an echocardiographic imaging protocol.

The data showed that 11% of echocardiograms were missing images that could evaluate the acute angle of origin. In addition, 13% of the images did not contain images that could effectively evaluate proximal interarterial course, 33% had no color Doppler imaging of the proximal intramural course, and 62% were missing images necessary to diagnose a high ostial takeoff.

There was a poor association in kappa statistics between the institutional reports and the ICL review for diagnosis in origin of coronary artery, interarterial course, intramural course, and acute angle takeoff (kappa=0.74, 0.11, –0.03, 0.13, respectively).

The researchers also found a significant dissociation between the surgical findings and the ICL reviews and institutional reports.

They note that TTE “is the most common initial screening tool for diagnosis of AAOCA in children and often is an incidental finding, because most patients are asymptomatic. Because the lesion is uncommon, echocardiography laboratories have developed institution-specific of methods of assessing and managing this condition.”

The authors recommended forming a new standardized reporting method and imaging protocols to allow for additional study of AAOCA. Other imaging techniques like transesophagel echocardiography, computed tomography angiography, and cardiac magnetic resonance should be considered for patients with ischemic symptoms when TTE is inconclusive.


  1. Lorber R, Srivastava S, Wilder T, et al. Anomalous Aortic Origin of Coronary Arteries in the Young: Echocardiographic Evaluation With Surgical Correlation. J Am Coll Cardiol. October 28 2015;8(11):1239-49. doi: 10.1016/j.jcmg.2015.04.027.