E J Meijboom (Lausanne, CH) Which athlete can re-enter his active sports career? After re-implantation of an abnormal origin of a coronary artery

Transcription

1 E J Meijboom (Lausanne, CH) Which athlete can re-enter his active sports career? After re-implantation of an abnormal origin of a coronary artery

2 Coronary Anomalies Congenital and Isolated Angiographic Series 1,2 % Autopsy Series 0,3 %

3 High risk group: inter-arterial course Left Coronary Artery from Right Sinus Right Coronary Artery from Left Sinus Single Orifice Separate Orifices Intramural Traject

4 Left Coronary Artery from Right Sinus Absolute indication for corrective intervention Form the single largest group of Coronary Anomalies with Sudden Death during or immediately after exercise Little of no forewarning, if so, syncope or chest pain

5 Right Coronary Artery from Left Sinus Relative indication for corrective intervention Form a smaller group of Coronary Anomalies with Sudden Death during or immediately after exercise Usually silent, but sometimes causing syncopes and/or chestpain

6 Intramural Course

7 Trans-œsophageal echo: LCA from RCS with extended intra-mural course Sports Related Hyperventilation Sudden Cardiac Death in Athletes 7

8 CT of the same LCA from RCS with even more clear the intra-mural course

9 3D CT reconstruction of RCA from LCS running inter-arterial

10 Referrals by decade to the Cleveland Clinic for management of ACAOS passing between the great vessels from the 1970s to Krasuski R A et al. Circulation 2011;123: Copyright American Heart Association

11 Young competitive athlete Personal and family history Physical examination 12-lead rest ECG Negative findings Positive findings Eligibility for competition No cardiovascular disease Further examination Cardiovascular disease European Heart Journal 2005 Management according to established protocols

12 Surgical techniques used to correct anomalous coronary arteries Re-implantation Unroofing Bypass grafting

13 What do we know about follow-up of coronary artery re-implantation? Arterial Switch Ross operation/aortic root replacement Abnormal origin of the coronary arteries 13

14 Arterial Switch 170 AS-pts: follow-up angiography in 59 Surgical coronary sequellae 5/59 pts. 3 stenosis of a coronary ostium 2 occluded left ostium Initially asymptomatic but showed: polymorphic VES on ECG moderate LV dysfunction large irreversible perfusion defects on scintigraphy. Both pts developed ventricular fibrillation at the age of 14 years. One patient did not survive. The other patient required implantation of a defibrillator stenosis of the right coronary ostium Hutter P. A. et al.; Eur J Cardiothorac Surg 2000;18:

15 Arterial Switch Long-term patency and function of translocated coronary arteries Coronary artery abnormalities detected at cardiac catheterization following the arterial switch operation for transposition of the great arteries, R. E. Tanel et al, Am. Journal of Card, ASO-pts : follow-up angiography Surgical cor. sequellae 13/366 pts (3%) 3 left main cor. art. stenosis, 2 occlusion 1 ant. desc. cor. art. stenosis, 2 occlusion 1 right cor. art. stenosis, 1 occlusion 3 small cor. art. fistulas left main cor. art. stenosis 1 pt died suddenly 1 pt is lost to follow-up 10 pts are alive and asymptomatic up to 11 years after surgery

16 Ross operation/arterial Switch Myocardial Blood Flow and Flow Reserve After Coronary Reimplantation in Patients After Arterial Switch and Ross Operation Conclusion: Michael Hausern et al, Deutsches Herzzentrum, Munich, Germany. Circulation Re-implantation of the coronary arteries has adverse effects on myocardial perfusion because in Ross and ASO patients, the myocardial blood flow after vasodilatation was significantly reduced 2 ASO pts are asymptomatic, no clinical signs of coronary dysfunction but in contrast to Ross pts they show stress-induced perfusion defects on PET scanning and attenuated coronary flow reserve.

17 Ross operation/arterial Switch All Pts asymptomatic, normal echocardiographic left ventricular function normal exercise capacity no cardiac medications Perfusion defects differed in the 2 groups: procedure of reimplantation? Nevertheless, the function of re-implanted the coronary arteries remains a matter of concern, prognostic implications must be discussed Close follow-up is mandatory, even in clinically asymptomatic patients.

18 Copyright 2008 The Society of Thoracic Surgeons Rhythm and conduction disturbances after the Ross procedure Pasquali S. K. et al.; Ann Thorac Surg 2008;85:

19 Evaluation of Myocardial Ischemia After Surgical Repair of Anomalous Aortic Origin of a Coronary Artery in a Series of Pediatric Patients, Julie A. Brothers et al, J Am Coll Cardiol, 2007 Prospective evaluation of myocardial ischemia after surgical repair of anomalous aortic origin of a coronary artery with an inter-arterial course 24 pts, all had unobstructed neo-coronary ostia by echocardiogram and all were asymptomatic median age 12(5-18) yrs; follow-up 5(2 to 48) mnths 16 (67%) had anomalous right coronary exercise stress test stress echocardiogram stress myocardial perfusion scan

20 Evaluation of Myocardial Ischemia After Surgical Repair of Anomalous Aortic Origin of a Coronary Artery in a Series of Pediatric Patients, Julie A. Brothers et al, J Am Coll Cardiol, 2007 Results: Post-operative evaluations suggestive of ischemia in: 1 ALCA pt (reversible apical septal and mid-anteroseptal hypokinesis on SE) 8 ARCA pts. 2 inferior ST-segment depression on EST and subsequently developed anterolateral Q waves 2 blunted blood pressure response with EST 1 fixed apical inferior hypokinesis on SE, 2 had reversible perfusion defects on MPS 1 fixed perfusion defect on MPS.

21 Evaluation of Myocardial Ischemia After Surgical Repair of Anomalous Aortic Origin of a Coronary Artery in a Series of Pediatric Patients, Julie A. Brothers et al, J Am Coll Cardiol, 2007 Conclusions: Subclinical changes suggestive of ischemia might occur despite patent neo-coronary ostia, notably after ARCA repair. The implication of these results on indication for surgery and subsequent sudden death risk is unknown. Serial EST, SE, and MPS are essential in evaluating ongoing ischemia risk after AAOCA repair

22 Long-Term Outcome and Impact of Surgery on Adults With Coronary Arteries Originating From the Opposite Coronary Cusp Richard A. Krasuski,Dari Magyar, Stephen Hart, Vidyasagar Kalahasti, Robert Hobbs, Gosta Pettersson, Eugene Blackstone cardiac catheterizations over a 35-year period at the Cleveland Clinics 301 anomalous coronary art, 54 (18%) with an interarterial course from opp. sinus of Valsalva 79% anomalous RCA from the left cusp or 21% anomalous LMC from the right cusp 28 out of 54 patients underwent surgical repair, no perioperative deaths Referrals by decade to the Cleveland Clinic for management of ACAOS passing between the great vessels from the 1970s to Krasuski R A et al. Circulation 2011;123: Copyright American Heart Association

23 Survival free from death based on initial medical or surgical management in patients with ACAOS passing between the great vessels. At 10-year follow-up, there was no difference in survival (P=0.65). Krasuski R A et al. Circulation 2011;123: Copyright American Heart Association

24 Young competitive athlete Personal and family history Physical examination 12-lead rest ECG Negative findings Positive findings Eligibility for competition No cardiovascular disease Further examination European Heart Journal 2005? Cardiovascular disease Management according to established protocols

25 Abnormal origin of the coronary arteries 36th Bethesda Conference Task Force 2: Congenital heart disease Thomas P. Graham Jr MD, FACC, Chair, David J. Driscoll MD, FACC, Welton M. Gersony MD, FACC, Jane W. Newburger MD, MPH, FACC, Albert Rocchini MD and Jeffrey A. Towbin MD, FACC 1 Detection of coronary anomalies of wrong sinus origin in which a coronary artery passes between great arteries should result in exclusion from all participation in competitive sports. 2 Participation in all sports three months after successful operation would be permitted for an athlete without ischemia, ventricular or tachyarrhythmia, or dysfunction during maximal exercise testing.

26 Conclusion Athletes may re-enter their active sports career after re-implantation of an abnormal origin of a coronary artery only after their: 12 lead ECG has normal ST-T segments TEE shows normal Doppler-flow in both coronary arteries Exercise ECG shows no ST-T segment depression Normal Scintigraphy No coronary obstruction on CT Stress MRI shows normal myocardial perfusion

27 Conclusion? May athletes re-enter their active sports career after re-implantation of an abnormal origin of a coronary artery after their: 12 lead ECG has normal ST-T segments TEE shows normal Doppler-flow in both coronary arteries Exercise ECG shows no ST-T segment depression Normal Scintigraphy No coronary obstruction on CT Stress MRI shows normal myocardial perfusion?

28 Coronary Anatomy LCA origin in Right Coronary Sinus courses between AO and PA

29 Exercise scintigraphy: no signs of ischaemia, nl LV perfusion and contractility, EF 66% 29

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31 Trajet inter-artériel de l ACD CHU Zürich : 1 cas

32 Double ostium Origine intra-murale

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34 Double ostium Réimplantation coronarienne orthotopique CHU Zürich : 1 cas

35 Ostium unique AMI IVA Flux compétitifs CHU Zürich : 1 cas