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.